F0684

G

Failure to Assess, Treat, and Document Multiple Wounds and MASD

Staten Island, New York Survey Completed on 03-25-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide treatment and care in accordance with professional standards and physician orders to maintain a resident’s highest practicable physical well-being. The resident was admitted with diagnoses including end-stage renal disease on hemodialysis, diabetes mellitus, and protein-calorie malnutrition, and was assessed on admission with intact skin and no pressure ulcers. A Braden Scale assessment identified the resident as at moderate risk for pressure injury. Despite a wound care consultation request being entered by a nurse, there was no documented wound assessment, no description of the wound, and no evidence that the attending physician was notified at that time. Moisture-associated dermatitis of the sacrum and bilateral buttocks was not formally assessed until days later by the wound care RN, who documented moisture-associated dermatitis and obtained a physician order for topical treatment.

Between the initiation of treatment and the resident’s subsequent transfer to the hospital, there was a lack of consistent documentation of treatment application and wound progression. The treatment record showed the last documented treatment on one date with no further documentation of treatment or evaluation of effectiveness for several days. A nurse practitioner later documented moisture-associated skin damage to the sacrum and issued a new order for hydrophilic cream, followed by another change in treatment to Medi-honey and calcium alginate, but there was no documented evidence that the effectiveness of these treatments was evaluated. The resident was then transferred from dialysis to the emergency room with increased leukocytosis. Hospital records documented multiple wounds, including moisture-associated skin damage to the sacrum/coccyx, stage I and II pressure injuries to the trochanters, deep tissue injuries to both heels, and other wounds to the left bunion and toes. On hospital discharge back to the facility, the resident was documented with a stage III sacral ulcer, unstageable and deep tissue injuries to the hips, deep tissue injuries to both heels, dry gangrene of toes, and partial thickness skin loss at the left bunion.

Upon readmission to the facility, the admitting nurse documented a pressure wound to the sacrum, wounds to bilateral hips, gangrene to all toes, and bilateral heel wounds, but did not notify the physician or nursing supervisor and did not initiate care plans, instead expecting the wound care nurse to reassess. The physician’s readmission note mentioned only moisture-associated skin damage to the sacrum and did not identify the stage III sacral ulcer or other wounds listed in the hospital discharge summary. A subsequent physician order for collagenase ointment did not specify the body site, and the treatment administration record showed it was given on only two days before being discontinued. The impaired skin integrity care plan addressed only moisture-associated skin damage to the sacrum and did not include the multiple additional wounds documented by the hospital. The wound care RN’s post-readmission assessment documented only a right hip superficial abrasion and sacral moisture-associated dermatitis, with bilateral lower extremities and feet described as unremarkable, which did not correlate with the hospital’s documentation of bilateral heel deep tissue injuries, gangrenous toes, and left bunion skin loss. There was no documented evidence of treatment for four wounds: the right hip, left bunion full thickness skin loss, and bilateral gangrenous toes. Interviews with facility staff and the wound care consultant confirmed that hospital skin assessments were not fully reviewed, that unit nurses deferred to the wound care nurse for skin issues, that some wounds were not assessed or reported, and that treatment effectiveness and wound progression were not consistently documented. This deficient practice resulted in actual harm to the resident, though it was not cited as Immediate Jeopardy.

Additional interviews further detailed the actions and inactions contributing to the deficiency. The nurse practitioner acknowledged not following up on the sacral moisture-associated skin damage, relying on unit nurses to notify them if the wound healed or required additional treatment, and did not recall gangrenous feet and toes. The RN who first requested the wound consult admitted there was no documentation of their assessment or physician notification and stated that unit nurses were responsible for providing treatment and notifying the wound care RN of deterioration, while the wound care RN was responsible for monitoring and documenting effectiveness. The readmitting RN acknowledged unwrapping the resident’s leg dressings, observing necrotic heels and toes, but failing to notify the physician or supervisor or initiate care plans. The wound care RN stated they did not review the hospital skin assessment because they preferred to assess with their own eyes, and asserted that the resident did not develop pressure ulcers in the facility. The unit manager stated they saw documentation of wounds in the hospital record but did not notify the wound care nurse and did not get involved with skin assessments. The wound care specialist PA reported assessing only the areas directed by the wound care RN and was unaware of some documented wounds. The DON and Administrator acknowledged that the nurse who first noted skin changes should have notified the physician and that the wound care nurse should have reviewed hospital discharge documentation and compared it to the resident’s condition on readmission.