F0686

D

Failure to Assess, Document, and Care Plan for Pressure Ulcers and Skin Breakdown

Aurora, Missouri Survey Completed on 03-18-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide pressure ulcer care and prevention consistent with its own policy and professional standards for two residents. The facility’s skin integrity policy required an admission skin condition and pressure ulcer risk assessment, weekly skin and wound assessments by licensed nurses, daily CNA skin observations with prompt reporting of changes, timely documentation of initial ulcer observations, and immediate notification of the resident, representative, and physician at the earliest sign of a pressure ulcer. For Resident #3, the comprehensive MDS dated 02/26/26 documented an existing Stage III pressure ulcer and the need for pressure-reducing devices and pressure ulcer care, yet the care plan dated the same day did not include any problem, goal, or interventions related to this Stage III ulcer. The Nursing Admission/Readmission Data Collection Assessment dated 02/27/26 documented no impaired skin integrity and no open areas, despite a hospital post-acute handoff dated 02/22/26 indicating a pressure ulcer to the midline sacral spine. The medical record contained no documented admission skin assessment.

Subsequent nursing documentation for Resident #3 showed further failures in assessment, measurement, and timely intervention. Progress notes on 03/06/26 and 03/07/26 recorded “excoriation” to the buttocks but did not include wound measurements, descriptive characteristics, or documentation of physician and family notification. A wound assessment dated 03/09/26 at 3:01 p.m. identified a facility-acquired Stage III pressure ulcer on the coccyx with 50% slough, serosanguinous drainage, and specific measurements, and noted that the family and physician were notified; this was the first documented wound assessment after admission. Although the assessment indicated the care plan was reviewed and updated, the care plan did not reflect the identified Stage III pressure ulcer at that time. Physician orders for weekly skin assessments, a low air loss mattress, and wound treatment were entered beginning 03/09/26 and 03/12/26, but the TAR showed wound treatment was not initiated until 03/12/26. There was no further wound documentation until a 03/15/26 progress note describing moderate purulent drainage with odor, and a 03/17/26 skin assessment documented a larger Stage III coccyx ulcer with increased slough and new orders for Santyl. CNA and LPN interviews indicated the wound was noticed around 03/09/26 with slough and green drainage, that no admission or weekly skin assessments had been completed, and that the wound was likely present on admission but could not be proven due to missing assessments.

For Resident #4, the facility also failed to assess, document, and care plan for skin breakdown and pressure ulcer risk. The care plan dated 12/22/25 contained no problem or interventions related to risk for skin breakdown or existing skin breakdown, despite an admission MDS indicating severe cognitive impairment, risk for pressure ulcers, and the need for pressure-reducing devices. A physician order dated 02/02/26 directed barrier cream to the coccyx/peri-area every shift for prevention, and the Nursing Admission/Readmission Data Collection Assessment dated 02/15/26 documented no impaired skin integrity. However, a bath assessment dated 02/16/26 noted “bumps” on the resident’s bottom, and the charge nurse did not sign this form. The resident was later hospitalized, and a 02/21/26 progress note recorded that a family member reported the hospital had found two bed sores on the resident’s backside with a current MRSA infection. When the resident returned from the hospital on 02/28/26, a progress note documented shearing to bilateral buttocks with blanchable erythema, but there was no documented wound assessment, no new wound care orders, and no physician or family notifications related to these findings. From 02/28/26 through 03/05/26, the record contained no skin assessments, no wound-related progress notes, no new wound care orders, and no updates to the care plan regarding skin breakdown or risk, despite staff interviews indicating that wounds on the resident’s bottom had been present up to about two months earlier and that staff had been applying ointment.

Interviews with staff and leadership further demonstrated systemic failures in implementing the facility’s skin integrity policy and monitoring processes. A CNA reported not being aware of nurses completing wound monitoring rounds since the new DON was hired, did not believe nurses were completing skin assessments timely, and had not seen nurses measure wounds, though they occasionally asked for assistance with repositioning during wound care. A CMT stated that if a new or worsening open area was observed, it should be reported to the charge nurse for assessment, documentation, and physician/family notification, but records did not show this occurring consistently. An LPN stated that skin assessments and wound measurements should be completed weekly and that new open areas should trigger assessment, measurement, documentation, and notifications, yet he was not aware of anyone completing weekly wound rounds. The DON acknowledged that admission and weekly skin assessments were expected, that responsibility for wound and skin assessments had shifted from a former ADON to charge nurses, that she did not fully understand the electronic system or how nurses were cued to complete assessments, and that she had not audited skin assessments. She also stated that weekly wound monitoring and measuring became her responsibility after the ADON left and that she did not complete them until the end of the week because she was unaware of all required steps. The Administrator and MDS Coordinator both described expectations that new open areas be immediately assessed, measured, documented, and care planned, with prompt physician notification and implementation of prevention measures, but the documented care for Residents #3 and #4 did not meet these stated expectations.