Failure to Accurately Assess and Timely Treat Pressure-Related Wounds
Penalty
Summary
The facility failed to accurately and comprehensively assess and timely treat pressure-related skin impairments for two residents following readmission. For one resident, the readmission skin assessment documented a skin impairment on the right buttock but did not include a description of the wound or its size, contrary to facility policy requiring documentation of location, stage, length, width, and depth. A physician progress note later indicated a new small wound on the buttock with a request for wound care follow-up, yet the wound, identified on February 9, 2026, was not comprehensively assessed until the wound physician evaluated it on February 18, 2026. At that time, the wound was identified as MASD on the right buttock, measuring 2.0 x 1.4 x 0.1 cm, partial thickness, and a Medihoney treatment was ordered. The DON confirmed that this wound, identified upon readmission, was not comprehensively assessed until the wound physician visit. For the second resident, the readmission skin assessment noted scattered scabs on the abdomen and left leg. A subsequent skin assessment by the wound nurse documented a Stage 2 pressure ulcer to the sacrum present on admission. The wound nurse reported that they recheck residents' skin within 24 hours of admission to identify and address all skin impairments and confirmed that this resident was admitted with a Stage 2 sacral ulcer. A physician order for daily topical Thera Honey (Medihoney) to the sacrum was written, but the November Treatment Administration Record showed no evidence that the sacral wound was treated until several days later. Additionally, a wound NP note documented intact skin on one date, followed two days later by a note from the same NP describing a Stage 3 sacral pressure ulcer present on admission, measuring 3.0 x 2.0 x 0.2 cm, with continuation of Medihoney ordered. The DON confirmed there was no documented evidence of treatment for the sacral wound during the initial days after readmission and was unaware of the NP’s earlier inaccurate documentation of intact skin.
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