F0686

D

Delayed Complete Assessment and Staging of Pressure Ulcers on Readmission

Hamburg, New York Survey Completed on 03-13-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure timely and complete assessment of pressure ulcers for a resident readmitted with multiple existing wounds. Facility policy required that all skin surfaces be inspected on admission, that risk factors be documented on the Skin Risk Data Collection Tool upon admission or change in condition, and that the Assistant Director of Nursing or designee initiate a weekly skin status evaluation when a pressure ulcer or chronic wound was identified. The policy also required that wound assessments include type, site, stage, size (length, width, depth in centimeters), description/characteristics, and treatment. The Admission Nursing Evaluation policy required compilation of physical and skin status information upon admission to determine care needs and further assessment.

Resident #258 had significant medical conditions including cervical cancer, rheumatoid arthritis, and a vesicovaginal fistula, and was documented on the Minimum Data Set as cognitively intact, requiring substantial/maximal assistance for bed mobility, and having multiple pressure ulcers present on admission/readmission (one stage 3, one stage 4, and three unstageable ulcers). The comprehensive care plan identified impaired skin integrity and included interventions such as administering preventive treatments per provider order, monitoring skin daily during care, protecting skin with pressure reduction devices, and evaluating and measuring skin/wound sites at least weekly with documentation of outcomes and treatment progress. However, the Nursing Admission Evaluation completed by Registered Nurse #2 on the readmission date only described general wound locations and approximate sizes for some areas (e.g., buttock ulcer “stage to be determined,” small open areas on thigh and calf, heel and ankle wounds) and did not include staging or precise measurements for the pressure ulcers.

Review of nursing progress notes, weekly skin status documentation, and medical visit notes from the date of readmission through several days afterward showed no evidence that a full pressure ulcer assessment, including measurements and staging, was completed during that period. The Medical Director’s note shortly after readmission referenced a chronic stage 4 sacral ulcer and directed readers to nursing notes for full assessments and measurements, but such documentation was not found. A complete wound assessment with staging and measurements was not documented until the Wound Care Consultant’s evaluation several days later, which detailed extensive stage 4 sacral/coccyx/bilateral gluteal fold ulcers and additional unstageable and stage 3 ulcers with specific dimensions. Interviews with an LPN, RN #2, the Medical Director, the Assistant DON, and the DON confirmed that facility expectations and practice were that an RN should complete full wound staging and measurements within 24 hours of admission/readmission, that RN #2 did not document stages or measurements and reported not being trained to do so, and that no one was contacted for guidance despite this lack of comfort, resulting in a delay in obtaining the required full assessment.