F0686

D

Failure to Maintain Continuous Treatment and Monitoring for Stage 2 Coccyx Pressure Ulcer

Watertown, New York Survey Completed on 03-20-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide necessary pressure ulcer treatment and services, consistent with professional standards, to prevent new ulcers and promote healing for a resident admitted with a Stage 2 coccyx pressure ulcer. The facility’s wound care policy required an interdisciplinary process for prevention, identification, assessment, treatment, and monitoring of wounds, with nurse managers responsible for comprehensive skin assessments, obtaining provider orders, and overseeing wound care. On admission, the resident’s assessment by the RN Unit Manager documented redness and a dime-sized Stage 2 pressure ulcer on the coccyx, and the admission MDS identified the resident as at risk for pressure ulcers, with moderate cognitive impairment, frequent incontinence, and dependence for toileting and hygiene. Despite this, there was no documented evidence of wound care orders for the coccyx at admission, and no wound care orders were in place for the first five days.

The comprehensive care plan initiated shortly after admission identified an actual/potential skin integrity impairment related to impaired mobility and referenced following facility protocols for treatment, monitoring and documenting the wound, and reporting signs of infection. A skin-only evaluation later documented skin issues on the back and coccyx, and a provider order was eventually entered to apply a foam dressing to the coccyx every three days for protection. A subsequent RN progress note stated that wound care orders were put in place and the wound healed. The resident was then hospitalized and readmitted with a reopened Stage 2 coccyx pressure ulcer, and admission assessment again documented this wound. A provider order to resume previous orders was entered, but the foam dressing order was discontinued two days later, and an RN progress note shortly thereafter documented that the resident’s skin was clear at that time.

Later, a weekly skin check by an LPN documented a pressure ulcer on the coccyx, and a family call reported an open area on the resident’s buttocks, with the nurse manager notified and assessing the resident. There was no documented skin-only evaluation on the date following the family complaint, and an LPN note documented the resident’s refusal to be repositioned on their side for an open area on the right buttock. An RN progress note a few days later, after assessment with the wound care nurse, described the coccyx as red with no open areas. New provider orders for Stage 2 coccyx pressure ulcer treatment were not entered until nearly two weeks after the LPN’s skin check documented the pressure ulcer, resulting in a 12-day period without wound care orders for the Stage 2 coccyx ulcer. Interviews with the RN Unit Manager, LPNs, the wound nurse, and the DON confirmed gaps in obtaining and maintaining wound care orders, lack of consistent wound monitoring and documentation, and uncertainty about why the wound was not tracked and treated continuously as required by facility policy.