Failure to Monitor and Manage MASD Leading to Stage 3 Sacrococcygeal Pressure Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to provide ongoing monitoring and timely assessment of a resident’s skin condition, resulting in deterioration from a left buttock Moisture Associated Skin Disorder (MASD) to a sacrococcygeal Stage 3 pressure ulcer with slough formation. During observation, CNAs repositioned the resident for wound care, revealing an open sacrococcygeal wound without a dressing, in contact with a urine-soiled disposable brief. One CNA stated that the wound dressing had fallen off earlier that morning during incontinence care and admitted she forgot to notify the RN or the ADON/Wound Care Coordinator. The ADON/WCC confirmed that the open wound should have been covered and that she was unaware of the wound’s deterioration until the surveyor’s observation. The ADON/WCC assessed the wound and described it as a pressure ulcer on the sacrococcygeal area with 80% slough and 20% reddish tissue with serosanguinous drainage, measuring 1.5 cm x 1 cm x 0.1 cm, and acknowledged that it had worsened since the prior week’s wound rounds with the wound care physician. She applied the same treatment ordered for MASD (zinc oxide and xeroform gauze with dry dressing) and later stated that this treatment was not appropriate for an open wound with slough formation, but that she used it until new physician orders could be obtained. The night shift RN reported that she had been treating a left buttock MASD that was now dry and healed, and that she was not aware of any sacrococcygeal pressure ulcer. The day shift RN reported that she had been aware of an open wound between the buttocks in the sacrococcygeal area, described its characteristics, and had been applying zinc oxide, xeroform, and a bordered dressing, but there was no indication that the physician had been notified of this change prior to the survey. Record review showed that the resident had multiple diagnoses including history of falls, fractures, muscle weakness, and unsteadiness, and had a Braden scale assessment indicating severe risk for skin impairment. The care plan documented a pressure ulcer and risk for further skin impairment, with MASD on the left buttock. The most recent wound assessment by the wound care physician prior to the survey described a non-pressure MASD wound on the left buttock that was healing. Facility policies required daily skin monitoring by CNAs, weekly skin checks by licensed nurses, weekly wound documentation with detailed characteristics, daily assessment of dressings, treatment based on wound etiology, and immediate physician notification for wounds with complications or not healing as anticipated. Despite these policies, the resident’s wound progressed and changed location from the left buttock MASD to a sacrococcygeal Stage 3 pressure ulcer without timely recognition, accurate identification, or physician notification, and with inconsistent documentation of wound site and etiology.
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