Uncovered Stage 4 Sacral Pressure Ulcer Not Reported or Redressed
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident with a Stage 4 sacral pressure ulcer received necessary treatment and services consistent with professional standards of practice. The resident was an elderly male with severe cognitive impairment, a BIMS score of 4, and diagnoses including diabetes mellitus. His entry MDS documented a Stage 4 pressure ulcer on the sacrum present on admission, and his care plan identified this ulcer with goals for healing and being free from infection, with interventions including treatment as ordered and monitoring. Physician orders directed staff to cleanse the sacrum and bilateral buttocks Stage 4 wounds with wound cleanser, pat dry, apply Santyl and calcium alginate, and cover with a dry dressing daily, with additional PRN orders if the dressing became soiled or dislodged. On the day of the surveyor’s observation, the treatment administration record showed the last wound treatment had been administered two days earlier, before the order was changed to three times weekly. During incontinence care, a CNA was observed cleansing the resident and turning him using a draw sheet. The resident’s sacral wound was observed to be open, uncovered, and draining onto the brief, and the CNA completed care by applying a clean brief and leaving the resident in bed without a dressing over the wound. There was no documentation in the resident’s March progress notes indicating that the wound dressing had been missing earlier that day. In interviews, the CNA stated she had removed the resident’s dressing that morning because it was peeling off and had fecal matter on it, acknowledged she was aware she was not allowed to remove dressings, and admitted she failed to notify the nurse or treatment nurse to replace it, despite prior training to do so. The charge RN and the wound care nurse both reported they had not been informed that the dressing had come off and stated their expectation that CNAs notify nursing staff so the dressing could be replaced per scheduled and PRN orders. The wound care nurse confirmed she had applied a dressing at the last treatment and expected nurses to monitor the dressing each shift and follow PRN orders if it became soiled or dislodged. The facility’s wound dressing change policy stated that dressings should be changed if feces seep beneath the dressing, but no training records were provided to support staff education on these procedures.
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