The October inspection revealed systematic failures in wound assessment for a resident with multiple pressure ulcers, including one wound that showed full-thickness tissue loss extending through all layers of skin into underlying structures.
The resident, identified as R1 in the inspection report, was admitted with dehydration, Parkinson's disease, anxiety and weakness. Her Braden Scale assessment on October 16 showed a score of 13, indicating moderate risk for developing pressure sores.
That same day, staff documented an unstageable pressure ulcer on her left buttock measuring 3 centimeters by .75 centimeters. The wound bed showed 100 percent granulation tissue, described as red and moist with a bumpy appearance from new capillary growth. Despite this clinical presentation indicating a stage III pressure ulcer, staff continued coding it as unstageable.
A second wound emerged on the resident's left iliac crest, the curved area on the hip bone. This wound measured 3.5 centimeters by 1 centimeter by .75 centimeters deep, with drainage present on the dressing and tunneling underneath the skin surface. The drainage was moderate and purulent, appearing white, yellow, green or brown.
Staff left the wound characteristics section incomplete for this injury.
Six days later, the same buttock wound was suddenly reclassified as stage I, the earliest and mildest form of pressure injury characterized by reddened, unbroken skin. The wound had actually shrunk to 3 centimeters by .35 centimeters, but staff noted the surrounding tissue was macerated and reddened.
A registered nurse was instructed to assess the change in wound status.
The same day, staff discovered a new wound on the resident's coccyx, the bottom bone of the spine, measuring 2.5 centimeters by 1 centimeter. They left the description section blank but noted 100 percent granulation tissue with macerated and reddened surrounding tissue.
During a subsequent nursing assessment, the wound on the iliac crest was reclassified as non-pressure related despite its location and characteristics. The assessment noted full-thickness tissue loss, a severe wound classification indicating damage extending through all skin layers into fat, muscle, tendon or bone.
The physician was notified about this wound's status, and staff requested a wound consultation.
Meanwhile, the buttock wound was again classified as unstageable during another nursing assessment.
When inspectors interviewed RN-B on October 31, she acknowledged being new to her role and explained her documentation process. She said she looked at nursing data collection when coding the Minimum Data Set, the standardized assessment tool used for Medicare and Medicaid reimbursement.
"The data collection she looked at said R1 had an unstageable pressure ulcer on admission which was why she coded it that way," according to the inspection report.
RN-B admitted there were issues with the facility's wound charting system.
The inspection found that accurate wound staging is critical for proper treatment and federal reporting requirements. Pressure ulcers progress through distinct stages, from stage I redness to stage IV wounds extending to bone, muscle or supporting structures. Unstageable wounds are those covered by dead tissue that prevents visual assessment of the wound bed.
The resident's wounds showed clear clinical indicators that should have guided proper staging. Granulation tissue, the red, moist, bumpy tissue that forms during healing, typically indicates a deeper wound than stage I. Full-thickness tissue loss automatically qualifies as stage III or IV depending on depth.
The facility's documentation errors extended beyond simple miscoding. Staff failed to complete wound characteristic sections, left description fields blank, and provided inconsistent staging for the same wound over time.
The tunneling present in the iliac crest wound represented a particularly serious complication. Tunneling occurs when infection or pressure creates channels beneath the skin surface, often indicating deeper tissue damage and increased infection risk.
Purulent drainage from this wound suggested possible infection, yet staff initially failed to classify it as pressure-related despite its location on a bony prominence where pressure ulcers commonly develop.
The inspection noted that accurate assessment drives treatment decisions and resource allocation. Understaging wounds can lead to inadequate treatment, while overstaging may result in unnecessary interventions.
Federal regulations require nursing homes to conduct comprehensive assessments and ensure accuracy in their Minimum Data Set submissions. These assessments determine Medicare reimbursement rates and quality ratings that families use to select facilities.
The facility's wound charting problems, acknowledged by nursing staff, represented systemic issues rather than isolated errors. When basic wound characteristics remain undocumented and staging changes arbitrarily, residents may not receive appropriate care.
For the resident with Parkinson's disease, accurate wound assessment was particularly crucial. Parkinson's patients often have limited mobility and difficulty repositioning themselves, increasing pressure ulcer risk. Her moderate Braden Scale score already indicated elevated risk requiring vigilant monitoring.
The presence of multiple wounds on pressure points suggested inadequate prevention measures or delayed recognition of developing injuries. The coccyx and iliac crest are classic locations for pressure ulcers in bedridden or wheelchair-bound residents.
Staff's failure to maintain consistent documentation created confusion about wound progression and healing. The buttock wound's reclassification from unstageable to stage I, then back to unstageable, suggested either poor clinical judgment or inadequate training in wound assessment.
The physician notification for wound consultation indicated clinical concern about the iliac crest wound's severity, yet this same wound had been inadequately documented and characterized initially.
Federal inspectors classified this as a minimal harm violation, but the resident continued living with multiple wounds of uncertain staging and potentially inadequate treatment protocols based on inaccurate assessments.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Good Samaritan Society - Blackduck from 2025-10-31 including all violations, facility responses, and corrective action plans.
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