F0686

D

Failure to Assess and Treat Resident’s Pressure-Related Wounds

Philadelphia, Pennsylvania Survey Completed on 03-30-2026

Penalty

No penalty information released

Summary

The facility failed to provide ordered treatment and complete assessment for pressure-related skin breakdown for a resident at risk for altered skin integrity. Facility policy required nursing staff and practitioners to assess and document significant risk factors for pressure ulcers and to perform a full assessment of any pressure sore, including location, stage, measurements, exudate, necrotic tissue, mobility status, current treatments, and support surfaces, with practitioners ordering appropriate wound treatments. The resident had multiple diagnoses including Type 2 diabetes mellitus with hyperglycemia, chronic kidney disease stage 3, atherosclerotic heart disease, prior cerebral infarction with dysphagia, and severe cognitive impairment (BIMS score of 0). The comprehensive care plan identified risk for altered skin integrity related to incontinence and impaired mobility, with interventions such as biweekly skin audits, reporting skin changes to the physician, and use of pressure-reduction devices.

Despite these identified risks and care plan interventions, documentation showed that on one date in early February an open area on the resident’s right buttock was noted without any measurements, description, or staging. Later in February, wound tracking documented an open area on the resident’s right anterior thigh measuring 3 cm x 3 cm, again without any additional description or staging. Review of the February medication administration record revealed no evidence that any treatment was obtained or provided for the right anterior thigh wound. In an interview, the DON confirmed that no treatment had been provided for this 3 cm x 3 cm wound, demonstrating a failure to follow the facility’s pressure ulcer/skin breakdown protocol and to obtain and implement wound treatment for the identified open area.