F0686

G

Failure to Assess, Communicate, and Treat Pressure Injuries for High-Risk Residents

Florissant, Missouri Survey Completed on 03-26-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide ongoing skin monitoring, timely assessment, physician notification, and ordered treatment for residents with actual or potential pressure injuries. Facility policies required physician orders for wound care, review of care plans, and detailed documentation of wound assessments, treatments, and notifications. Policies also required that all treatments and services be documented with date, time, provider, assessment findings, resident response, refusals, and notifications. Despite these requirements, staff did not consistently assess skin, obtain or implement treatment orders, or document wound care and changes in condition.

For one resident admitted with intact skin and a Braden score indicating risk for pressure ulcers, weekly skin assessments were incomplete and subsequent wound care was delayed and poorly documented. An initial comprehensive skin assessment shortly after admission showed dry, intact skin and no wounds, and a Braden assessment identified the resident as at risk. A weekly skin assessment was documented one week later as intact, but the following week’s assessment was not completed. On a later date, a progress note documented a new skin shear on the left buttock, with a foam dressing applied and a message sent to the NP for treatment orders; however, there was no documentation of NP response, no new treatment orders on the POS, and no documentation that the responsible party was notified. The next day, staff documented only that the resident remained on antibiotics and that incident follow-up related to a new wound showed no changes, without recording wound size, physician or family notification, or new wound care orders. Over the next several days, there was no documentation regarding the wound.

Subsequently, a comprehensive skin assessment documented the presence of wounds and identified a new sacral wound but did not include size or stage, and staff recorded that no notifications were required. An order was entered for the resident to be followed by wound care, but no specific wound care orders were present at that time. A wound care management note the next day described a sacral wound measuring 3.0 cm by 5.0 cm with 60% necrotic and 40% granulation tissue and set out a treatment plan including NS cleansing, Santyl, calcium alginate, and foam dressing, but the POS did not yet contain corresponding treatment orders. Wound care orders were not entered until the following day, and the TAR showed the first treatment documented as applied another day later. Subsequent wound care notes documented changes in wound size and tissue composition and updated treatment plans, but the TAR showed missed documentation of ordered treatments on multiple dates. A family member reported discovering an open area on the buttocks during bathing and later observing a brown and black wound with a foul odor under a dressing dated two days earlier. The ADON acknowledged being informed by the family member, checked the record and found no wound documentation, did not assess the resident, and did not document the family’s concerns, stating that wound issues and documentation were the responsibility of the Wound Nurse. The Wound Nurse recalled being informed by the family, did not complete a comprehensive skin assessment, did not measure or stage the area, and only wrote an order for specialized wound care team evaluation without notifying the physician or obtaining treatment orders. The Wound Nurse also acknowledged missing a weekly skin assessment, not performing a formal skin assessment for a two-week period, and that the resident developed the wounds in the facility.

For a second resident with quadriplegia, bowel incontinence, and very high risk for pressure ulcers, the facility failed to assess and treat an existing pressure injury documented at the hospital prior to admission. The resident’s care plan identified risk for skin breakdown and included interventions such as administering treatment as ordered, applying barrier cream, and checking skin during daily care. A hospital discharge summary referenced a sacral pressure injury, and a Braden assessment at the facility showed a very high risk score. However, there were no documented skin assessments from admission through several days of stay, and the progress note on the day of transfer back to the hospital for respiratory distress contained no skin evaluation. A hospital nurse reported that the resident returned to the hospital with a deep tissue injury to the coccyx and was still wearing the same protective dressing that hospital staff had applied before discharge to the facility, indicating that the dressing had not been changed during the facility stay. The facility’s Medical Director and primary care physician for both residents stated he was not informed of the first resident’s wounds when initially identified and was not informed that the second resident had a coccyx dressing on readmission, and he stated that residents should be assessed head to toe on admission or readmission and that weekly skin assessments should be completed at minimum, noting existing problems with communication regarding pressure ulcers and wound care.