F0686

D

Failure to Obtain Timely Wound Orders and Provide Ongoing Care for Existing Pressure Ulcer

Rockport, Indiana Survey Completed on 03-10-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide necessary treatment and services for an existing pressure ulcer and to ensure timely wound care orders and assessments for a resident with significant risk factors. The resident’s diagnoses included muscle wasting and atrophy, protein-calorie malnutrition, anemia, and influenza. An admission MDS indicated the resident had no unhealed pressure ulcers on admission but was at risk for developing them and was dependent for mobility, including rolling side to side in bed. A Braden scale assessment later indicated low risk, but the care plan documented an alteration in skin integrity with an unstageable pressure injury, with interventions to evaluate and change treatment as needed and to observe and report new concerns.

On admission, a weekly wound evaluation dated 1/10/26 documented a Stage 1 pressure ulcer on the coccyx measuring 7 cm by 4 cm with no depth, and noted redness on the coccyx with a small open wound toward the right buttocks, with a comment that the wound nurse should evaluate and provide ideas to help with healing. Nursing notes from 1/10/26 described a small open lesion on the coccyx with surrounding redness and irritation, and a 1/12/26 note documented that the resident reported needing to sleep on her side because of a bedsore. The resident was later admitted to the hospital, where a wound/ostomy evaluation on 1/17/26 identified an unstageable pressure injury to the buttocks present on arrival, with 100% slough and a small adjacent Stage 2 pressure injury, and a facility readmission assessment documented a pressure ulcer to the sacrum with specific measurements.

Despite these findings, the MAR/TAR showed that the resident did not receive routine wound treatment and had no wound treatment orders to the coccyx from 1/10/26 to 1/14/26 prior to hospital transfer, and again had no routine wound treatment or orders from readmission on 1/21/26 through 2/8/26. A nurse’s note on 2/6/26 indicated that during a skin check a coccyx wound was found and a risk assessment was being submitted. Subsequent wound assessment reports on 2/18/26, 2/25/26, and 3/4/26 documented an unstageable pressure ulcer on the coccyx, present on admission, with varying percentages of granulation and slough and moderate serosanguinous exudate. In interviews, an LPN stated that initial admission or readmission wound assessments should trigger obtaining a wound treatment order and that the wound care nurse should complete weekly assessments, while an RN acknowledged that coccyx wound assessments were not documented from readmission on 1/21/26 until 2/18/26, contrary to the facility’s policy requiring necessary treatment and services for pressure injuries.