Failure to Reposition Resident with Pressure Wound
Summary
The facility failed to ensure timely repositioning of a resident with a known pressure wound, leading to a deficiency in skin care management. On multiple observations throughout the day, the resident was found lying on their back without any repositioning or use of pillows to offload pressure from the sacral wound, despite the care plan indicating the need for routine repositioning and assistance with bed mobility. The resident, who has paraplegia and heart failure, was admitted with a stage three pressure ulcer and requires substantial assistance to reposition. The facility's policy on wound prevention and management emphasizes the importance of redistributing pressure for residents at risk of pressure injuries. However, the observations revealed that the resident was not repositioned every two hours as expected, and no devices or pillows were used to alleviate pressure on the sacral wound. The resident reported experiencing constant pain from the wound, and the Director of Nursing acknowledged the expectation for repositioning every two hours, which was not met.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Staff failed to prevent the development of a sacral stage 3 pressure ulcer in a cognitively impaired, highly dependent resident with multiple comorbidities and documented risk for impaired skin integrity. The care plan called for monitoring pressure areas, turning and positioning, and assisting the resident to bed during the day for pressure relief, but observations showed the resident remaining in a wheelchair for many hours on multiple days, largely to accommodate a spouse’s preference for dining room meals. Skin assessments progressed from no issues to MASD on the sacrum and then to an open sacral wound, which was later staged by a wound care physician as a stage 3 pressure ulcer of pressure etiology. The DON reported relying on staff assurances that weight shifting occurred in the wheelchair, and there was no indication that the responsible party was educated about the need for pressure offloading, while the resident was also observed receiving no encouragement or assistance with meals.
A resident with multiple comorbidities and a history of pressure ulcers was re-admitted with intact skin but did not receive consistent weekly skin assessments or have a care plan addressing pressure ulcer prevention. Facility staff failed to document or implement preventive interventions such as regular repositioning and use of pressure-relieving surfaces until after two advanced-stage pressure injuries were discovered during a facility-wide skin sweep. Documentation for turning and repositioning was inconsistent, and required assessments and care planning were not completed as per facility policy.
A resident with multiple comorbidities was admitted with an unstageable pressure ulcer, but staff did not perform a comprehensive wound assessment or initiate treatment orders until several days later. Despite facility policy requiring prompt evaluation and intervention, nursing staff failed to document wound details or contact providers for care, resulting in a lack of timely wound management until a wound NP intervened.
A resident with an open sacral wound was not thoroughly assessed or treated upon admission due to a failure to document the physician's order in the treatment administration record. For several days, the wound was not monitored or treated as required, and daily assessments failed to identify the presence of a pressure injury. The deficiency was confirmed through record review and staff interviews.
A resident with multiple comorbidities and pre-existing wounds did not consistently receive ordered wound assessments, treatments, or nutritional supplements, and there were gaps in documentation and implementation of turning and repositioning interventions. These failures led to the development of new Stage 2 and Stage 3 pressure injuries and deterioration of existing wounds.
Staff failed to implement timely and appropriate interventions for pressure injury prevention and treatment for three residents, including delays in following wound care recommendations, improper infection control practices during wound care, and lack of updates to care plans and treatment records. There was confusion among staff regarding responsibility for entering and implementing wound care orders, resulting in missed or delayed treatments.
Failure to Prevent and Adequately Offload Sacral Pressure Ulcer
Penalty
Summary
Facility staff failed to provide necessary care to prevent the development of a sacral stage 3 pressure ulcer in one cognitively impaired, highly dependent resident. The resident had Alzheimer's disease, heart failure, diabetes, severe impairment in daily decision-making (BIMS score 3/15), and required substantial to maximal assistance for most self-care and mobility tasks. The care plan identified a potential for impaired/compromised skin integrity related to bilateral lower extremity edema and incontinence, with interventions including observing pressure areas for redness, notifying the nurse of any redness, encouraging and assisting with turning and positioning, assisting the resident to bed during the day for pressure relief, and assisting with repositioning as needed. A low-air-loss mattress was not added until late February. Weekly skin assessments initially documented no skin issues on 2/4/26, with barrier cream used on both buttocks as a preventative measure due to incontinence. By 2/11/26, nursing documentation identified moisture-associated skin damage (MASD) on the sacrum, which continued to be documented on 2/18/26. On 2/22/26, nursing documentation described an open wound to the sacrum measuring 2 cm x 2 cm, which was not staged at that time but was cleaned with normal saline and covered. When the wound care physician first evaluated the resident on 2/24/26, the sacral wound was identified as a stage 3 pressure ulcer of pressure etiology, measuring 2.0 cm x 1.5 cm x 0.2 cm, with 100% granulation tissue and moderate serous drainage, and treatment with calcium alginate with honey was ordered. Despite the resident’s high risk for pressure injury and the presence of a sacral pressure ulcer, observations on multiple days showed the resident remaining in a wheelchair for extended periods. On 3/11/26, the resident was observed in a wheelchair in her room at approximately 11:00 AM and again at 3:50 PM. On 3/12/26, the resident was observed in bed at about 9:15 AM with breakfast, then out of bed in a wheelchair at 11:07 AM being taken to the dining room, and again in the wheelchair in her room at approximately 4:30 PM. On 3/18/26 at about 11:00 AM, the resident was again observed sitting in a wheelchair in her room. A CNA reported that the resident was out of bed daily before 11:00 AM because the spouse wanted the resident to have lunch in the dining room. The DON stated that direct care staff had assured her they shifted the resident’s weight when seated in the wheelchair, but there was no indication that the nursing team had educated the responsible party or power of attorney about the need to offload pressure to promote healing and prevent additional pressure ulcers, while the resident was also observed receiving no encouragement or assistance from staff with meals.
Failure to Prevent and Timely Identify Pressure Ulcers in At-Risk Resident
Penalty
Summary
Facility staff failed to implement necessary interventions, care, and services to prevent the development of pressure ulcers in a resident identified as being at risk. The resident, who had multiple comorbidities including end stage renal disease, diabetes, heart failure, dementia, and a history of sacral pressure ulcers, was re-admitted to the facility with intact skin. Despite being at risk, as indicated by a Braden Scale score of 17 and a history of previous pressure injuries, the resident did not have a care plan addressing pressure ulcer prevention, and no specific interventions were documented to prevent pressure-related injuries. Weekly skin assessments, as required by facility policy, were not consistently performed between the resident's re-admission and the discovery of two advanced-stage pressure injuries. The facility only identified the injuries during a facility-wide skin sweep, which was initiated after it was recognized that weekly skin reviews were not being completed. Documentation also showed inconsistent or missing records for turning and repositioning, which are critical interventions for pressure ulcer prevention, especially for residents with limited mobility and incontinence. Interviews with facility staff, including the Wound Care Nurse and DON, confirmed that preventive measures such as air mattresses and regular repositioning were only implemented after the wounds were discovered, rather than proactively based on the resident's risk profile. The care plan lacked interventions for pressure ulcer prevention and did not address the resident's refusal of care or changes in condition. Facility policies required systematic risk assessment, care planning, and intervention for at-risk residents, but these were not followed, resulting in the resident developing two advanced pressure injuries.
Failure to Timely Assess and Treat Pressure Ulcer on Admission
Penalty
Summary
Facility staff failed to thoroughly assess and implement timely interventions for the care of a pressure ulcer for one resident. Upon admission, the resident was noted to have an unstageable pressure ulcer on the right hip, but the initial assessment lacked a detailed description of the wound, including its size, appearance, condition of surrounding skin, and presence of drainage, odor, or pain. Daily skilled notes acknowledged the presence of the pressure ulcer but did not document any treatments or dressing changes. No comprehensive assessment or treatment orders were initiated for the pressure ulcer until five days after admission, when a wound nurse practitioner performed a thorough assessment and began appropriate wound care. The resident had multiple comorbidities, including congestive heart failure, atrial fibrillation, diabetes, obesity, and cognitive communication deficit, and was assessed as cognitively intact. Despite the presence of a pressure ulcer on admission and the absence of hospital-provided wound care orders, nursing staff did not contact the in-house provider, on-call provider, or wound nurse practitioner to obtain necessary treatment orders. Interviews with LPNs and the DON confirmed that no comprehensive wound assessment or treatment orders were documented prior to the wound nurse practitioner's intervention, and staff could not explain why appropriate actions were not taken when the wound was first identified. Facility policy required prompt reporting and documentation of changes in skin integrity, comprehensive wound assessments, and timely notification of providers for evaluation and treatment. These procedures were not followed, as evidenced by the lack of detailed wound assessment, absence of treatment orders, and failure to implement dressing changes for the pressure ulcer during the initial days after admission. The deficiency was confirmed through staff interviews, clinical record review, and facility policy review.
Failure to Assess and Treat Pressure Injury on Admission
Penalty
Summary
Facility staff failed to provide appropriate care and services for a pressure injury for one resident. Upon admission, the resident was documented as having an open wound on the sacrum, but the assessment lacked further descriptors such as measurements, stage, or wound characteristics. Although a physician's order was entered to cleanse the wound and apply a foam dressing, this order was not reflected in the medication or treatment administration records due to a scheduling error in the computer system. As a result, there was no evidence that the prescribed treatment was provided for three consecutive days. During this period, daily skilled assessments incorrectly indicated that the resident did not have impaired skin or a wound being monitored or treated. A subsequent body audit identified a stage three pressure injury on the sacrum, with specific measurements documented. Staff interviews confirmed that wound assessments and treatments are typically communicated and documented via the treatment administration record, but this process failed in this instance, leading to a lack of timely and appropriate wound care.
Failure to Provide Consistent Pressure Ulcer Prevention and Care
Penalty
Summary
Facility staff failed to provide adequate pressure ulcer care and prevention for one resident, resulting in the development of new pressure injuries and deterioration of existing wounds. The resident, who had multiple complex medical diagnoses including hypertension, diabetes, morbid obesity, hemiplegia, and pre-existing wounds, was admitted with significant risk factors for pressure injury development. Despite being assessed as moderate risk on the Braden Scale and requiring extensive assistance with mobility and ADLs, the resident did not consistently receive the ordered interventions and assessments necessary for pressure ulcer prevention and management. Clinical record review revealed missed or incomplete wound assessments on specific dates, as well as gaps in the administration of prescribed treatments and nutritional supplements intended to promote wound healing. Documentation showed that the air mattress, which was ordered to reduce pressure, lacked evidence of being in place or regularly checked for functionality. Additionally, the care plan interventions for turning and repositioning were not consistently implemented or documented, with multiple instances of missing or incomplete CNA documentation regarding repositioning and ADL care. Further review of medication and treatment administration records identified multiple days where wound care treatments and supplements such as Prostat, MVI, and Zinc were not administered as ordered, either due to being on order, not available, or left blank. The facility's own policies required weekly skin risk assessments and documentation of interventions, but these were not consistently followed. The cumulative effect of these failures led to the resident developing new Stage 2 and Stage 3 pressure injuries and a lack of timely response to changes in wound status.
Failure to Implement Timely Pressure Ulcer Prevention and Treatment Interventions
Penalty
Summary
Facility staff failed to implement timely and appropriate interventions to prevent and treat pressure injuries for three residents. For one resident, staff did not follow the wound nurse practitioner's recommendations for wound care, including delayed implementation of prescribed treatments and failure to provide an air mattress as recommended. Observations revealed improper infection control practices during wound care, such as not using personal protective equipment (PPE), cross-contaminating clean and dirty supplies, and placing clean gloves and wound cleanser on soiled bed linens. The resident reported not receiving heel boots as recommended, and documentation showed delays in updating care plans and treatment administration records to reflect new or worsening wounds. Another resident was admitted with moisture-related skin irritation and later developed a Stage 3 pressure ulcer. The wound nurse practitioner's recommendations for wound care and preventive measures, such as floating the heels, were not implemented. The treatment administration record did not show evidence of the recommended interventions being carried out, and the care plan was not updated to reflect the presence of the Stage 3 pressure ulcer or the necessary interventions. Interviews with staff revealed a lack of clarity regarding roles and responsibilities for implementing wound care recommendations, with some staff unaware of the process for ensuring that recommendations were entered into orders and care plans. A third resident developed a new wound during their stay, and the wound nurse practitioner's treatment recommendations were not implemented prior to discharge. The care plan was not updated to include the new wound, and the treatment administration record did not reflect the prescribed care. Staff interviews indicated that recommendations from the wound nurse practitioner were not always translated into actionable orders or care plan updates, and there was confusion about who was responsible for ensuring implementation. Facility policy required notification of providers and implementation of treatments as ordered, but this was not consistently followed.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
