Failure to Prevent and Manage Pressure Ulcers
Summary
The facility failed to provide appropriate pressure ulcer care and prevent new ulcers from developing for two residents. Resident R4 was admitted without a pressure injury or catheter but returned from hospitalization with a Foley catheter. The facility did not implement interventions to prevent medical device-related pressure injuries, failed to complete weekly measurements and assessments, and did not perform treatments as ordered. As a result, R4 developed a full-thickness wound extending from the tip of the penis through the meatus and down to the shaft. Despite documentation of pressure from the Foley catheter causing redness, pain, and drainage, the facility did not conduct weekly assessments or measurements of the affected area. Resident R6 was admitted without a pressure injury but developed a stage 2 pressure ulcer on the coccyx. The facility did not implement interventions to prevent the development of pressure injuries upon admission, failed to notify the physician when the wound worsened, and did not ensure proper hand hygiene during wound care. The wound management notes indicated discrepancies in documentation, with two entries for the same time and date, and treatments were not signed out as completed on the Treatment Administration Record (TAR) until several days later. The facility's policies on wound care and catheter care were not followed, leading to the development and worsening of pressure injuries in both residents. The lack of timely assessments, documentation, and communication with healthcare providers contributed to the deficiencies observed by the surveyors. The facility's failure to adhere to professional standards of practice for pressure ulcer prevention and care resulted in immediate jeopardy for the residents involved.
Removal Plan
- The facility reviewed the care plan of resident to identify and complete follow up, if indicated for concerns related to the catheter device. The resident was sent to hospital for evaluation.
- The facility identified all residents currently admitted to identify any possible similar events related to abnormal findings for residents with catheters at risk for injury including but not limited to pressure ulcers.
- Facility conducted a sweep of all residents with an indwelling foley catheter to ensure interventions are in place to prevent PI development.
- Skin assessments have been completed on all residents with an indwelling catheter.
- The facility initiated proactive education with licensed nursing staff on catheter care and pressure ulcer prevention.
- Nursing staff will be educated to ensure correct positioning to prevent tubing from being taut or causing pressure on the urethra.
- Nursing staff will be educated on monitoring of skin integrity on residents with catheters during cares, paying special attention to skin impairment and will be completed with the change in condition policy. Any findings will be reported immediately.
- The facility initiated a skills check list for licensed nursing staff for catheter care.
- The facility audited all residents with catheters with or without wounds related to catheter use to ensure orders were appropriate and treatment plans were in place for care as well as prevention of pressure ulcers.
- Proactive education on the use of stat locks for catheters.
- Documentation is to include weekly measurements and assessments if a pressure ulcer is identified. These are to be signed out in the TAR as ordered.
- The facility initiated education with licensed nurses to ensure physician orders are transcribed correctly to the MAR/TAR.
- Licensed Nursing Staff were also educated on documenting and reporting changes of condition at the time of the observation to the physician as well as the resident's responsible party and hospice.
- The facility initiated reeducation with all Licensed Nursing Staff on identifying and reporting Changes of Condition when newly identified changes in health status are identified.
- The facility initiated reeducation with all Licensed Nursing Staff on completion of a comprehensive assessment on all skin events with a noted change in size, shape, and clinical presentation at the time of discovery.
- The Licensed Nursing staff was reeducated on completing a notification to the MD, RP, and or Guardian at the time of identification.
- The Licensed Nursing Staff were reeducated on catheter care including but not limited to pressure ulcer prevention and treatment.
- The Licensed Nursing staff were reeducated on transcribing orders to the MAR/TAR as ordered.
- The facility will review orders daily in the Morning Clinical Meeting to ensure that preventative orders are in place for catheters to decrease the risk for pressure.
- The facility will review Matrix EHR (electronic health record) daily during Morning Clinical Meeting to identify Changes of Condition and ensure notifications/consultations were completed. Follow up will be completed if indicated based on the outcome of the audit.
- The facility will complete random audits 3x weekly with Licensed Nurses to gauge understanding related to completion of Changes of Condition. Remedial education will be provided at the time of completion of audits if indicated.
- The facility will complete random audits 3x weekly on catheters to ensure care is provided per clinical standards. To include proper placement of leg strap/stat lock to prevent pressure. Remedial education will be provided at the time of completion of audits if indicated.
- The facility will complete random audits 3x weekly on pressure ulcers to ensure care is provided per clinical standards. Remedial education will be provided at the time of completion of audits if indicated.
- The facility will complete random audits 3x weekly on treatment records and weekly skin assessments to ensure care is provided per clinical standards. Remedial education will be provided at the time of completion of audits if indicated.
- The facility will audit residents with medical device pressure injuries 3x weekly to ensure weekly assessments are documented in the medical record including measurements.
- The results of the audits will be reported to the quality assurance and performance improvement (QAPI) committee and adjustments will be made to frequency of audits based on findings.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with multiple comorbidities, moderate cognitive impairment, and a left heel wound did not receive consistent weekly skin assessments or accurate wound treatment as ordered. Facility records showed only two documented weekly skin assessments over several months, despite policy requiring weekly assessments. The TAR reflected nightly heel wound treatments as completed by various LPNs, but observation revealed a heel dressing that was two days old, with the DON confirming it had been dated ahead and signed on an earlier shift. An LPN acknowledged signing for a heel treatment he did not perform and stated he was unaware the resident had a heel treatment, demonstrating a failure to provide and accurately document ordered wound care.
A resident with multiple comorbidities and existing pressure ulcers was admitted and later readmitted with documented skin issues, but staff failed to complete comprehensive and ongoing skin assessments as required by facility policy. Initial documentation lacked measurements and detailed descriptions of pressure ulcers, and after readmission, only limited information on an abrasion, a heel scab, and a surgical incision was recorded, with no documented assessment of pressure ulcers. Despite the resident being followed by a wound clinic and having stage 3 pressure ulcers on the sacrum and right plantar foot per clinic notes, the facility did not complete the required weekly skin observation tools, and the DON confirmed there was no comprehensive documentation of wound status or healing.
Two residents at high risk for skin breakdown did not receive wound and incontinence care as ordered. One resident with a stage II sacral pressure injury and MASD remained on the back for several hours without the two-hourly checks, incontinence care, or repositioning that staff later described as expected, and was found heavily soiled with urine; when CNAs finally provided care, they noted MASD and a sacral wound but did not apply the ordered dressing, which an LPN later confirmed should have been in place. Another resident with paraplegia, chronic osteomyelitis, and a right posterior thigh/gluteal wound had a physician order for cleansing with liquid antibacterial soap and water and application of Prisma with a silicone border dressing, but an LPN instead used wound cleanser spray, applied a different collagen product, and performed the entire dressing change without changing soiled gloves between removing contaminated dressings and handling clean supplies, which the LPN and DON acknowledged did not follow the physician’s orders or clean technique.
Two residents did not receive consistent, professionally managed pressure ulcer care. One resident was admitted with a wound noted on assessment, but for weeks the only documented wound was a skin tear, there were no wound-care orders, and facility staff denied any buttock wounds despite a family photo and an outside RN’s documentation of open buttock areas and a stage 1 coccyx ulcer. Another resident with a care-planned stage 4 sacral pressure injury and specific MD orders for Aquacel AG and foam dressings every other day had multiple missed or unrecorded treatments on the TAR, and reported that dressings were not changed consistently and that only two nurses regularly performed the care. The regional RN verified the missing treatment entries, while the ADON, who stated an outside wound center managed the wound, was unaware of the missed treatments, contrary to the facility’s wound care policy requiring adherence to professional standards of practice.
A resident admitted with existing pressure sores and other comorbidities had an unstageable coccyx pressure ulcer documented as 2 cm by 2 cm with light serous exudate, but no specific wound care or dressing orders were initiated or documented for three days after admission. Wound care orders, including triad wound cream to the coccyx twice daily, were not started until several days later, by which time a wound NP documented the sacral wound as very large, measuring 11.5 cm by 11.2 cm with moderate serosanguinous exudate and involving the bilateral buttocks. The DON and Administrator confirmed that wound dressing orders were not initiated until three days after the resident’s admission.
A resident re-admitted after hip fracture surgery, with PVD, incontinence, impaired cognition, and full dependence for mobility, was assessed as at moderate risk for pressure ulcers but did not receive new preventive interventions such as pressure-reducing devices, a turning/repositioning program, or documented nutrition/hydration measures. No full skin assessment was documented after readmission until the resident’s daughter discovered a coccyx pressure ulcer that staff had not identified, and subsequent evaluations showed the wound progressed from Stage II to unstageable with infection, along with new suspected deep tissue injuries on both heels. Although orders were written for daily wound care, an air mattress, heel boots, offloading, and barrier cream, the TAR showed missed coccyx and heel treatments without documented refusals, and observation found heel boots not in place despite staff stating they were tolerated, while the care plan listed only providing treatments as ordered and did not reflect broader preventive measures.
Failure to Complete Ordered Heel Wound Care and Weekly Skin Assessments
Penalty
Summary
The deficiency involves the facility’s failure to complete weekly skin assessments and ordered wound treatments for a bedbound resident with a left heel wound. The resident, admitted with multiple diagnoses including morbid obesity, schizoaffective disorder, chronic pain syndrome, osteoarthritis, and major depression, had moderate cognitive impairment and required staff assistance for ADLs. Facility records showed that from the time the heel wound was identified on 12/18/25 through 03/23/26, only two weekly skin assessments were documented, on 02/03/26 and 03/17/26, despite facility policy requiring weekly assessments with each risk assessment. The resident’s care plan identified her as at risk for skin breakdown due to incontinence, decreased mobility, impaired cognition, and obesity, and noted she was resistive to care and turning and repositioning, with interventions including completion and monitoring of skin treatments per physician orders. Review of the physician’s order dated 03/06/26 showed a nightly and as-needed wound care regimen for the left heel, including cleansing, drying, applying collagen, and covering with a border foam dressing. The TAR from 12/18/25 through 03/24/26 showed the left heel wound treatment documented as completed, including entries by multiple LPNs on 03/21/26, 03/22/26, and 03/23/26. However, on 03/24/26, observation of the resident’s left heel with an LPN and the DON revealed the dressing was dated 03/22/26 and was two days old. The DON confirmed that the night-shift LPN who worked on 03/21/26 had dated the dressing 03/22/26 and signed the TAR on 03/21/26. Another LPN stated he did not know the resident had a heel treatment, verified he had not completed the treatment on 03/22/26, and stated he was not falsifying documentation when signing it off. The DON further verified that only two weekly skin assessments had been completed during the review period, contrary to facility policy and expectations.
Failure to Perform Required Weekly Skin Assessments for Resident With Pressure Ulcers
Penalty
Summary
The deficiency involves the facility’s failure to complete routine and comprehensive skin assessments for a resident with existing pressure ulcers and other skin impairments, as required by facility policy. On admission, the resident’s nursing assessment documented pressure ulcers on the bottom of the left foot and right outer heel, but did not include measurements or detailed descriptions of these ulcers. The resident was later discharged for planned spinal surgery and then readmitted, at which time the admission assessment noted an abrasion on the left buttock with measurements, a scab on the left heel with measurements, and a surgical incision on the back of the neck without measurements or description. There was no assessment of any pressure ulcer at readmission, and no subsequent skin assessments or documentation of wound healing were found in the medical record, despite a posted notice indicating the resident had a wound clinic appointment. Wound clinic notes obtained by the facility showed that the resident had a stage 3 pressure ulcer on the sacrum and a stage 3 pressure ulcer on the right plantar foot. The DON confirmed that, aside from the limited admission assessments, the facility had no comprehensive assessments or documentation of healing for any of the resident’s skin impairments. Corporate nursing staff stated that the facility had a single wounds/skin impairments policy, which required a licensed nurse to complete a skin observation tool at least every seven days detailing any wounds or skin impairments. Corporate Nurse #503 verified that the resident’s non-pressure-related skin impairment was not assessed weekly by either the facility or the wound clinic, demonstrating noncompliance with the facility’s own wound/skin assessment policy.
Failure to Follow Physician Orders and Aseptic Technique for Wound and Incontinence Care
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered pressure ulcer care, moisture-associated skin damage (MASD) care, and timely incontinence care and repositioning for residents at high risk for skin breakdown. One resident with dementia, a persistent vegetative state, total dependence for ADLs, incontinence, and tube feeding was assessed as high risk for pressure ulcer development with a Braden score of 11. After readmission from the hospital, this resident had a stage II coccyx pressure injury and excoriation/MASD to the groin and thighs, with physician and wound specialist orders for cleansing with wound cleanser or normal saline, application of zinc barrier cream to the wound bed and buttocks, coverage with a dry or foam dressing, and dressing changes every shift and as needed. The plan of care also included barrier cream after incontinence episodes, routine skin inspection, and use of a pressure-reducing mattress. On the observed day, CNAs provided incontinence care and repositioned this resident onto his back at 7:45 A.M. Continued observation from 8:00 A.M. to 11:13 A.M. showed the resident remained on his back without further checks for incontinence care or repositioning, despite staff later stating the resident was to be checked, changed, and repositioned every two hours. At 11:13 A.M., an LPN entered the room, exposed the G-tube site, and found the resident heavily soiled with urine in an adult brief but did not address the incontinence care needs while completing G-tube and tube feeding care. At 11:58 A.M., two CNAs removed the brief and again found the resident heavily soiled with urine; they cleansed the resident with disposable wipes and incontinence spray cleanser and noted MASD and a sacral wound, but no dressing was applied to these wounds at that time, despite a current physician order for a dressing. The LPN later verified that a physician order for a dressing to the MASD and sacral wound was in place and that no dressing was present. A second resident with paraplegia, chronic osteomyelitis, stage IV pressure ulcers to the right buttock and sacral region, incontinence, and dependence for ADLs also experienced deficient wound care. This resident had an order for an open area on the right posterior thigh to be cleansed with liquid antibacterial soap and water, patted dry, and treated with Prisma and a silicone border Zetuvit dressing once daily and as needed. During observation of wound care, an LPN gathered supplies, donned gloves and a gown, and exposed the right posterior gluteal fold wound, where the dressing was dislodged. The LPN removed the soiled dressing and packing, then, without changing soiled gloves, opened gauze packaging, cleansed the wound with wound cleanser spray instead of the ordered liquid antibacterial soap and water, and patted the wound dry with gauze. The LPN then opened and applied a collagen purcol pad instead of the ordered Prisma, and covered the wound with a silicone border dressing, all while continuing to use the same soiled gloves. The LPN confirmed that gloves were not changed between handling soiled dressings and clean supplies and that the products used did not match the physician’s orders. The DON verified that the wound treatment was not administered as ordered by the physician.
Failure to Provide and Document Consistent Pressure Ulcer Care
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate care and treatment for existing pressure ulcers and to prevent new ulcers from developing for two residents. One resident was admitted with multiple medical conditions, including peripheral vascular disease and osteonecrosis, and the admission assessment and baseline care plan noted the presence of a wound without documenting its location. From admission through several weeks, nursing progress notes contained no documentation of any wounds other than a skin tear, and there were no physician orders for wound care. Despite this, the resident’s responsible party reported pressure wounds on the buttocks, provided a photograph showing two open reddened areas near the gluteal fold, and stated that the facility was not providing wound care. A urology RN later documented two open skin areas on the left medial buttock and a stage 1 pressure ulcer on the coccyx when the resident presented for a procedure, while facility nursing leadership and staff continued to deny the presence of any buttock wounds beyond the documented skin tear. The second resident had an existing care plan for a sacral pressure injury related to impaired mobility, urinary incontinence, and cancer, with interventions including performing ordered treatments and completing preventive measures. The resident’s MDS indicated cognitive intactness, need for assistance with rolling, frequent urinary incontinence, a colostomy, and one stage 4 pressure ulcer. Physician orders specified cleansing the sacrum with soap and water, patting dry, filling the wound and undermining with Aquacel AG rope, and applying a foam dressing every other day and as needed. However, review of the Treatment Administration Records showed multiple dates in two consecutive months when the ordered sacral wound treatments were not recorded as completed. The resident with the sacral pressure ulcer reported that dressings were not being changed consistently and attributed the development of the wound to not being repositioned, though she was unsure whether it originated in the facility or the hospital. She further stated that only two nurses regularly changed her sacral dressing. The regional RN confirmed the missing treatment entries on the TAR, and the ADON, who indicated that an outside wound center managed the resident’s wound care and had recently changed the treatment frequency, was unaware that treatments were not being completed and suggested agency nursing staff usage as a possible factor. The facility’s own wound care policy required that wound care be provided using professional standards of practice, which was not followed as evidenced by the lack of documented and consistently provided wound care for both residents’ pressure ulcers.
Failure to Initiate Timely Wound Care for Existing Pressure Ulcer
Penalty
Summary
The facility failed to initiate timely wound care for a resident with a pressure sore, resulting in a period of three days without specific wound treatment orders after admission. The resident was admitted with diagnoses including cellulitis, prediabetes, and pressure sores, and a wound assessment documented on 09/05/25 identified an unstageable coccyx pressure ulcer measuring 2 cm by 2 cm with light serous exudate. Despite this documented pressure sore, no specific wound care orders were initiated or documented as completed until 09/08/25, when triad wound cream was ordered to be applied to the coccyx twice daily. The first wound nurse practitioner assessment on 09/09/25 documented the wound as significantly larger, measuring 11.5 cm by 11.2 cm with moderate serosanguinous exudate, and the wound NP recalled the sacral wound as very large and encompassing the bilateral buttocks, though she did not recall being informed of the initial smaller measurement and considered the possibility that the initial measurement was inaccurate. The DON and Administrator confirmed that no wound dressing orders were initiated for this resident until three days after admission, and this failure to promptly initiate wound care was cited as a deficiency under Complaint Number 2749003.
Failure to Implement and Document Pressure Ulcer Prevention and Treatment
Penalty
Summary
The deficiency involves the facility’s failure to provide timely and appropriate pressure ulcer prevention and treatment for a resident at risk for skin breakdown. The resident was re-admitted after a left hip fracture with open reduction and internal fixation and had known risk factors including peripheral vascular disease, incontinence, impaired cognition, dependence on staff for mobility and transfers, frequent urinary incontinence, and bowel incontinence. A Braden assessment completed after readmission identified the resident as at moderate risk for pressure ulcers, but there was no evidence that new preventive interventions were implemented at that time. The resident’s care plan called for weekly skin assessments and a pressure redistribution mattress, but after readmission there was no documented skin assessment until the resident’s daughter identified a coccyx skin alteration, and the resident did not have pressure-reducing devices for bed or chair, was not on a turning/repositioning program, and had no documented nutritional or hydration interventions for skin management. The resident’s daughter submitted a concern form reporting that after the resident’s return from the hospital, the RN did not properly check the resident back into the facility and that staff were unaware of a coccyx pressure ulcer the daughter observed, which she described as several inches in size and facility-acquired. A protective dressing was first applied only after the daughter brought the ulcer to staff attention. Subsequent assessment by a consulting wound nurse practitioner documented a new in-house acquired wound on the sacrococcygeal area initially staged as a Stage II pressure ulcer with moderate serosanguineous drainage, and later facility wound documentation described the same area as an unstageable pressure ulcer with extensive eschar. The wound later cultured positive for proteus and pseudomonas, and the resident was treated with antibiotics. The wound practitioner also documented new suspected deep tissue injuries on both heels, with measurements recorded for the left heel on the day of identification and delayed documentation of right heel measurements several days later. Treatment orders were initiated for cleansing and dressing the coccyx/sacral and buttock areas with mesalt and dry dressings daily, use of an air mattress, heel boots as tolerated, offloading, and barrier cream. However, the treatment administration record showed missed wound treatments on specific days for the coccyx/sacral area and missed heel treatments on at least one day, with no documentation that the resident refused care. Observation showed that heel boots ordered for prevention were not in place while the resident was in bed, despite no recorded refusals and staff confirmation that the boots were tolerated. The DON confirmed that staff did not administer certain ordered treatments, that the coccyx pressure ulcer was first identified by the family rather than staff, that no new interventions were implemented when the resident’s Braden score increased from low to moderate risk, and that the care plan for the pressure ulcers contained only the intervention to provide treatments as ordered, contrary to the facility’s wound and skin care policy requiring timely risk assessment, repeat skin assessment within 24–72 hours of admission, and implementation of resident-specific preventive interventions.
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