F0686

G

Failure to Accurately Assess, Care Plan, and Implement Wound Care for Pressure Injuries

Tacoma, Washington Survey Completed on 03-19-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide necessary treatment and services consistent with professional standards of practice to prevent the development and worsening of pressure ulcers/injuries for a resident admitted with coccyx skin breakdown and at moderate risk for pressure injury. On admission, the resident had two coccyx wounds documented as skin tears without detailed wound characteristics, and the Braden Scale score was 14, indicating moderate risk due to moisture, activity, mobility, and friction/shear issues. The initial skin integrity care plan identified actual skin impairment and included general interventions such as keeping skin clean and dry, using lotion, encouraging nutrition, weekly skin assessments, and monitoring/documenting wounds, but it did not include resident-centered interventions addressing specific Braden risk areas or pressure ulcer prevention measures such as repositioning, offloading, or moisture management tailored to the resident’s condition.

In the weeks following admission, nursing documentation about the resident’s skin condition was inconsistent and incomplete. Progress notes alternated between stating that the resident had no wounds and describing a pressure ulcer with drainage and slough, excoriation of the buttocks, and open areas on the coccyx, without consistent measurements or staging. Weekly skin audits at times reported no irregularities despite other notes indicating significant skin issues. The contracted wound care clinician (WCC) did not evaluate the coccyx wounds until 14 days after admission, at which time the resident had a large unstageable coccyx pressure injury with extensive eschar. Although the WCC recommended specific treatments, including twice-daily dressing changes, an air mattress, and turning/repositioning every two hours, the care plan was only minimally updated to add an air mattress and did not document the unstageable pressure injury, pressure offloading, repositioning frequency, or other individualized interventions based on the Braden assessment.

Over the subsequent weeks, the facility failed to consistently perform and document weekly wound evaluations and did not accurately transcribe or implement physician and WCC wound care orders. Treatment Administration Records showed that orders for twice-daily wound care were entered as once daily, and instructions to leave an acidic wound cleanser on the wound bed for 10 minutes were omitted. Weekly wound evaluations were missing for multiple weeks, and when the WCC documented worsening of the coccyx wound to Stage IV with increasing size and eschar, the care plan still was not updated to reflect the wound stage, detailed interventions, or additional pressure-relieving devices recommended by the WCC. The resident’s coccyx pressure injury continued to worsen in size and depth, and a new deep tissue injury developed on the right heel, despite WCC orders for heel protectors and offloading. The care plan eventually added general instructions to encourage repositioning and elevate heels with pressure-relieving boots, but it still did not document the presence or stage of the coccyx Stage IV pressure ulcer or the heel DTI. Interviews confirmed that wound orders were incorrectly transcribed, weekly wound evaluations were not routinely completed, and the initial coccyx wounds had been misidentified as skin tears rather than Stage II pressure ulcers, contributing to avoidable worsening of the resident’s pressure injuries.