Failure to Maintain Continuous Ordered Treatment for Coccyx Wound
Penalty
Summary
The facility failed to provide treatment according to a resident’s wound care orders and plan of care for a coccyx wound. Record review showed that on 12/10/25 an order was written to apply skin guard ointment to the genital area and coccyx every day and evening shift for skin healing, and this was documented as completed on the evening of 12/10/25 and the morning and afternoon of 12/11/25 before being discontinued on 12/11/25. A new order effective 12/12/25 directed staff to apply skin guard to the genital area every day and evening shift for wound healing, but this order did not include treatment to the coccyx. No other coccyx wound treatment was ordered or documented from 12/12/25 through 12/16/25. A new coccyx wound order was not written until 12/17/25, directing staff to cleanse with wound cleaner, apply medi-honey to the wound bed, and cover with a border foam dressing as needed. During an interview on 3/24/26, the DON was informed of the gap in coccyx wound care orders and documentation between 12/12/25 and 12/17/25 and stated she would look for wound care documentation; no additional documentation was provided by the time of survey exit. The deficiency involved one resident reviewed for wound care whose coccyx wound lacked ordered and documented treatment for several days following a change in the treatment orders.
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