Failure to Prevent and Identify Pressure Ulcers
Summary
The facility failed to provide adequate care and services to prevent and timely identify pressure ulcers and injuries for three residents, resulting in Immediate Jeopardy and serious life-threatening harm. Resident #37 developed six facility-acquired deep tissue pressure injuries and was hospitalized for osteomyelitis. Resident #86 developed unstageable pressure ulcers to the coccyx, left heel, and left lateral ankle, also requiring hospitalization for osteomyelitis. Resident #4 initially developed moisture-associated skin damage, which healed, but was later found to have an unstageable pressure ulcer to the coccyx. Resident #86 was admitted with diagnoses including a fracture and paraplegia, and was at risk for developing pressure ulcers. Despite being cognitively intact and requiring assistance with various activities of daily living, the facility failed to document turning and repositioning, and there were no shower sheets for a period. The resident developed multiple pressure wounds, which were not promptly identified or treated, leading to hospitalization for sepsis and osteomyelitis. Resident #37, with a history of peripheral vascular disease and diabetes, was at high risk for pressure wounds. The facility did not complete a Braden Scale assessment for nearly three years and delayed implementing an air mattress despite the resident's high risk. This resulted in the development of multiple pressure ulcers. Resident #4, with a history of psychosis and dementia, developed an unstageable pressure ulcer to the coccyx after initially having moisture-associated skin damage. The facility's failure to implement timely interventions and conduct regular skin assessments contributed to the worsening of the resident's condition.
Removal Plan
- Wound Nurse Practitioner assessed Resident #86's wounds and ordered new treatments as indicated.
- The Director of Nursing reviewed Resident #86's record and Resident #86 had the following interventions in place: Foley Catheter, Air mattress, Apply protective barrier cream after incontinent episodes and as needed, Assist with turning and repositioning as needed, Encourage Resident #86 to reposition self if able, Encourage/assist as needed to elevate heels off the mattress as tolerated, Pressure redistribution device in chair, Pressure reducing boots to bilateral feet as tolerated. May remove for care, Resident #86 uses half side rail for repositioning and bed mobility.
- The DON or designee implemented the following interventions for Resident #86: Limit time in chair to three hours, then back to bed for two hours before getting up again, ROHO cushion to wheelchair, Side to side turns only every two to three hours, which will be signed off in the treatment administration record when completed.
- WNP assessed Resident #4's wounds with no new orders given.
- The DON reviewed Resident #4's record and Resident #4 had the following interventions in place: Assist with turning and repositioning as needed, Pressure reduction mattress, Provide incontinence care as needed, Place washcloths in bilateral hands, clean hands between washcloth replacements, Assist with toileting needs, Provide perineal care after each incontinent episode; apply house barrier cream, Pressure relieving boots to be worn for prevention as tolerated.
- The DON or designee implemented the following interventions for Resident #4: Air mattress, ROHO cushion to wheelchair, Turn and reposition side to side every two to three hours, which will be signed off in the treatment administration record when completed, Pressure relieving boots to both heels.
- WNP assessed Resident #37's wounds and ordered new treatments as indicated.
- The DON reviewed Resident #37's record and Resident #37 had the following interventions in place: Apply protective barrier cream after incontinent episodes and as needed, Assist with turning and repositioning every two hours and as needed, Encourage/assist as needed to elevate heels off the mattress as tolerated, Provide a non-irritating surface to reduce friction or shearing forces, Provide incontinence care every two hours and as needed, Air mattress, Encourage Resident #37 to reposition self if able, Resident #37 uses half side rail for repositioning and bed mobility, Wheelchair with standard cushion with Dycem under cushion when out of bed for comfort and positioning.
- The DON or designee implemented the following interventions for Resident #37: No shoes until healed, Pressure reducing boots to bilateral feet.
- Residents with turn and reposition interventions had a physician order, and it would be signed off in the treatment administration record when completed.
- The DON or designee completed a skin assessment on all residents to ensure all pressure areas had been identified and treatment initiated.
- The DON or designee audited all residents with orders for splints to ensure the skin around it is checked on the daily basis for signs of pressure.
- The DON or designee audited all residents to ensure each resident had a shower sheet completed in the last seven days.
- The DON or designee audited all residents to ensure all residents had an updated quarterly Braden Assessment.
- The DON or designee audited all residents with moderate, high risk, and very high-risk Braden scores to ensure appropriate interventions are in place to prevent new pressure ulcers or worsening of present pressure ulcers.
- President of Clinical developed a Skin/Wound Clinical Program Best Practice that included the following: A shower sheet addressing the resident's skin condition must be completed with each shower to timely identify new areas, A skin assessment must be accurately completed by the floor nurse weekly, to timely identify new areas, Any time a resident is at risk for skin breakdown, appropriate interventions must be implemented immediately to prevent new development or worsening of pressure ulcers, Any time there is a new pressure area identified; a wound care treatment must be immediately initiated.
- The nursing staff were educated by the DON or designee on the facility Skin/Wound Clinical Program Best Practice.
- An ad hoc Quality Assurance Committee Meeting was held to review the plan.
- Weekly for four weeks, the DON or designee will review four residents to ensure shower sheets were completed with each shower.
- Weekly for four weeks, the DON or designee will review four skin assessments to ensure that the assessments were completed accurately.
- Weekly for four weeks, the DON or designee will review four residents at risk for skin breakdown to ensure appropriate interventions were implemented.
- Weekly for four weeks, the DON or designee will review all new pressure ulcers to ensure a treatment was initiated immediately.
- Weekly for four weeks, the DON or designee will review the residents with splints to ensure that the skin around it is checked daily for signs of pressure.
- The audits will be submitted weekly to the QA Committee for tracking, trending, and recommendations.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Failure to perform hand hygiene between glove changes during wound care. An LPN changed dressings on a resident with multiple pressure injuries, including a heavily draining, odorous buttock wound, an unstageable coccyx ulcer, and a left heel injury, but repeatedly removed dirty gloves and put on new gloves without cleaning hands in between. The LPN said she only washed her hands before starting and after finishing, while the DON stated hand hygiene was required each time gloves were changed during wound care.
A resident with multiple comorbidities and limited mobility developed a worsening right gluteal wound that progressed from an abrasion to an infected Stage 4 pressure ulcer with foul odor, purulent drainage, and sepsis requiring hospital transfer and surgical debridement. Staff documentation showed the wound deteriorated over time, but the facility could not show that the MD was properly notified of the changes or that timely action was taken. A left heel area also lacked documented treatment or prevention measures, and surveyors later observed a dark red/black area on the heel while the resident’s heels were flat on the bed.
Failure to Document and Measure Pressure Ulcer Weekly: A resident with a Stage 2 pressure ulcer, hospice status, impaired cognition, and significant care needs had a physician order for twice-weekly dressing changes and weekly wound measurements. Facility records showed multiple weeks with no wound documentation or notes that lacked wound description or measurement, despite the facility’s policy requiring weekly monitoring and detailed documentation of the ulcer, pain, mobility, treatments, and wound characteristics.
Failure to monitor and offload existing pressure injuries: A resident with encephalopathy, MI, and respiratory failure had stage 2 pressure ulcers to the tail bone and heel documented on admission, but no further wound monitoring was found. The care plan lacked repositioning and offloading interventions, and repeated observations showed the resident lying on their back with heels pressed on the bed and no pillows or other offloading devices in place. The resident said staff were not turning them or placing pillows under their feet, and the DON confirmed weekly assessments and pressure-reduction interventions were expected but did not occur.
Failure to complete and document ordered wound care for two residents with significant comorbidities and skin risk factors. One resident with ESRD, CHF, DM, and multiple foot wounds had repeated missing TAR entries and no progress note documentation for ordered dressing changes, and was later hospitalized with worsening wound infection and osteomyelitis after the wound care provider reported concern that the facility was not changing dressings as ordered. A second resident with DM and CKD had ordered sacral and heel wound care, but the record lacked skin assessment details, wound measurements, and descriptions of the wounds.
A resident with significant neurologic impairment, malnutrition, and dependence on staff developed a facility-acquired lower back pressure injury that progressed to a stage 4 wound with infection, sepsis, and surgical debridement. Surveyors observed prolonged time in the same position, a nonfunctioning air mattress, delayed meal assistance, and missing turning/repositioning documentation. Records and interviews also showed the wound worsened over time, with inadequate offloading noted in hospital documentation.
Failure to Perform Hand Hygiene During Wound Care
Penalty
Summary
The facility failed to perform hand hygiene between glove changes during pressure ulcer wound care for one resident who was cognitively intact, required substantial to maximal assistance with transfers, and had diagnoses including a thoracic vertebra fracture, muscle weakness, and right lower leg amputation. The resident was identified as being at risk for pressure ulcers and had wound orders for the left heel, right buttock, and gluteal crease. The wound assessment described a right upper buttock pressure ulcer measuring 5 cm by 6.5 cm by 2 cm with odor and heavy purulent dark brown drainage saturating the dressings, an unstageable coccyx pressure ulcer, and a deep tissue injury on the left heel with a drained blister and intact epidermal layer. During observed dressing changes, the LPN removed soiled dressings from the right buttock and gluteal fold, then removed dirty gloves and put on new gloves without performing hand hygiene. She repeated this pattern after cleaning the wounds and again while changing the left heel dressing, removing gloves and donning new gloves without hand hygiene before removing the old dressing, cleaning the heel, and applying the new dressing. The LPN stated she washed her hands before starting and after the dressing change, but did not think to perform hand hygiene when changing gloves. The DON stated nurses were to follow wound procedures during dressing changes, including hand hygiene each time gloves were changed, and that hand hygiene was done to ensure the wound does not become decontaminated when placing clean dressings.
Failure to Manage Worsening Pressure Ulcers and Document Physician Notification
Penalty
Summary
The facility failed to obtain orders and implement interventions for one resident with pressure ulcers, and the resident’s right gluteus abrasion deteriorated into an infected Stage 4 pressure ulcer. The resident was admitted with diagnoses including major depressive disorder, atrial fibrillation, obesity, osteoarthritis, and a left heel pressure ulcer. The resident was cognitively intact, required substantial to maximal assistance to roll in bed, and was dependent on staff for transfers. The care plan and MDS identified pressure ulcer risk and included interventions such as turning and repositioning every 2 hours, pressure relief devices, heel floating, weekly skin assessments, and wound specialist involvement. The right gluteus wound was first identified as an abrasion and was treated with ordered dressings, but serial skin issue reports documented progressive deterioration, increasing size, pain, drainage, odor, and slough. The wound was described as non-healing and later as unstageable, with purulent drainage and foul odor. Staff interviews showed that changes in the wound were often placed on reports or left on the physician’s desk, but the facility was unable to provide reproducible evidence that the physician was notified of the worsening wound or what response was given. The wound nurse practitioner stated she was not notified of deterioration between follow-up visits and that earlier notification could have allowed more aggressive treatment. The wound continued to worsen until the resident required bedside and then surgical debridement, IV antibiotics, and hospital transfer for shock and sepsis related to the infected pressure ulcer. Hospital records documented a Stage 4 buttock pressure wound with polymicrobial infection and sepsis due to the pressure ulcer. In addition, a left heel area noted by wound evaluation as callous-like skin with blanchable erythema and possible pressure component did not have documented treatment orders or preventive measures in the resident’s record, and later survey observation found a dark red/black closed area on the left heel while the resident’s heels were lying flat on the bed.
Failure to Document and Measure Pressure Ulcer Weekly
Penalty
Summary
The facility failed to follow physician orders and its pressure ulcer documentation policy for a resident with a Stage 2 pressure ulcer on the thoracic spine. The resident’s quarterly MDS identified moderately impaired cognition, substantial assistance needs for care, bed mobility, and transfers, hospice status with a life expectancy of 6 months or less, pain that had been severe during the assessment period, and use of scheduled and as-needed pain medication. The resident also had a pressure relieving device in the chair and on the bed. During an observation, an RN performed a dressing change, removed the old dressing, cleansed the area, and measured the wound at 0.7 cm x 0.4 cm; the RN described it as superficial with a red wound bed and well-defined edges and stated weekly wound documentation was completed in the progress notes. The physician’s telephone order directed staff to change the dressing to the thoracic spine twice weekly and measure the wound on Tuesdays until healed, while the facility’s pressure ulcer protocol required weekly monitoring and documentation of the ulcer’s location, stage, length, width, depth, surrounding tissue, wound bed, pain, mobility, current treatments, and active diagnoses. Review of the nursing progress notes showed five weeks in which the facility did not follow the order to measure weekly or document the pressure ulcer assessment per policy, including periods with no wound documentation or notes that lacked a description or measurement of the wound. Interviews with nursing staff and the DON confirmed the expectation that the wound should be assessed and measured weekly and documented in the progress notes.
Failure to Monitor and Offload Existing Pressure Injuries
Penalty
Summary
The facility failed to provide care and services to monitor actual pressure injuries and to prevent new pressure injuries for one resident who was reviewed for pressure injuries. The resident was admitted with diagnoses including encephalopathy, myocardial infarction, and respiratory failure, and was able to make needs known. During an interview, the resident stated that their sitting bones were sore. The resident was later sent to the hospital and returned to the facility. The admission nursing assessment documented a 6 cm by 10 cm stage 2 pressure ulcer to the tail bone and a 3 cm by 2 cm stage 2 pressure ulcer to the left heel, but no further monitoring of the pressure injuries was found in the EHR. A body check assessment did not list the pressure injuries, although it noted pressure ulcer prevention measures including pillow, offloading, and turning and positioning. The active plan of care showed the resident had declined a low air loss mattress, but no other interventions such as offloading and repositioning were listed. Multiple observations showed the resident lying on their back in bed with no offloading devices and heels pressed on the bed. The resident stated staff never put pillows under their feet or turned them on their side. Staff interviews confirmed that residents with pressure injuries should have positioning devices, frequent repositioning, weekly monitoring, and care plan interventions, but these were not in place for this resident.
Failure to Document and Complete Ordered Wound Care
Penalty
Summary
The facility failed to complete ordered pressure ulcer and wound care for two residents who were at risk for skin breakdown. One resident had multiple diagnoses including CKD, CHF, HTN, ESRD, muscle wasting/atrophy, anemia, and was cognitively intact with a BIMS score of 15. That resident required substantial to maximal assistance with toileting, was incontinent of urine and bowel, had two foot ulcers, a diabetic foot ulcer, and a wound infection, and was assessed as at risk for pressure ulcer development. For that resident, physician orders included daily wound care to the left calcaneus, right calcaneus, right plantar foot, and right medial foot, along with topical povidone-iodine to the right foot. The TAR for 5/2026 did not document completion of the ordered wound care on multiple dates, and the progress notes also lacked documentation that the treatments were completed on those dates. The resident’s hospital history and physical documented worsening wound infection, multiple wounds in both feet with significant purulent drainage and necrosis, and the resident reported that the nursing home should have been changing wound dressings daily but said that was not done. The wound care provider stated she was concerned the facility was not completing the dressing changes as ordered and sent the resident to the emergency room, where the resident was admitted with osteomyelitis of the right foot. The second resident had diagnoses including type 2 DM, stage 4 CKD, anemia, and HTN, and had a BIMS score of 15. The resident’s care plan identified risk for skin complications, and physician orders included daily wound care to the sacrum and right heel using wound cleanser, Medi honey, and bordered gauze. However, the nursing admission observation had no documentation that the skin was assessed, the nursing admission assessment documented skin conditions requiring monitoring/treatment without measurements, locations, or descriptions, and the skin assessment documented no new findings without documenting the current areas. There was no documentation of wound measurements or descriptions from 1/15/26 through the resident’s discharge to the hospital on 2/25/26.
Pressure Ulcer Care and Offloading Failure
Penalty
Summary
Failure to provide appropriate pressure ulcer care and prevent new ulcers from developing was identified for one resident who had multiple risk factors, including hemiplegia/hemiparesis following cerebral infarction, aphasia, vascular dementia, protein-calorie malnutrition, and dependence on staff for repositioning, transfers, dressing, hygiene, and eating. The resident’s MDS reflected she was at risk for pressure ulcers and was not on a turning/repositioning program at earlier assessment points. The resident later returned from the hospital with a stage 4 pressure ulcer and continued to have a facility-acquired wound on the lower back/spinal area that was documented as unstageable/deep tissue injury and later progressed to a stage 4 pressure ulcer with exposed bone and undermining. Record review showed the wound was first documented as a new in-house pressure ulcer on the lower back with erythema, edema, slough, and eschar, and subsequent notes described worsening size, depth, undermining, pain, and seropurulent drainage. The resident was hospitalized for sepsis secondary to an infected stage 4 lumbar pressure ulcer with deep soft tissue infection, and hospital records noted surgical debridement. Infectious disease documentation stated the lumbar decubitus ulcer was associated with likely spinous process erosion in the setting of inadequate offloading and recommended aggressive offloading and nutritional supplementation. Survey observations showed the resident remained in the same bed position for extended periods, with a wedge under the hip and the bed alarm/beeping noted, while meal assistance was delayed and the resident called out for food. On another observation, the air mattress pump was not functioning and the mattress appeared deflated, with the resident sunk into the bed. Staff interviews and record review also found missing turning/repositioning documentation, and the facility could not provide a complete investigation when requested. The resident’s care plan included turning/repositioning, pressure-reducing devices, and skin checks, but the report documented that the resident’s wound developed and worsened while these measures were not consistently evidenced in the record or during observations.
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