Failure to Prevent and Manage Pressure Injuries
Summary
The facility failed to provide necessary treatment and services to prevent and manage pressure injuries (PIs) for two residents, R1 and R2, leading to the development and worsening of PIs. R1 was admitted without a PI but was at risk for developing one. The facility did not implement adequate interventions, failed to conduct weekly comprehensive assessments, and did not update the care plan timely. As a result, R1 developed a facility-acquired PI that progressed to a stage 4. The facility's inaction included not staging the PI, not offering alternative repositioning schedules, and not educating R1 on the importance of repositioning. R2 was also admitted without a PI but was at risk due to severe cognitive impairment and other medical conditions. The facility did not complete comprehensive assessments or offer alternative interventions when R2 refused repositioning. Consequently, R2 developed two deep tissue injuries that worsened into multiple PIs, including an unstageable PI with undermining. The facility failed to stage the wounds when first noted and did not provide adequate interventions to prevent further deterioration. The deficiencies were identified through observations, interviews, and record reviews, revealing that the facility did not adhere to professional standards for PI prevention and management. The lack of timely assessments, staging, and care plan updates contributed to the worsening of the residents' conditions, indicating a failure to provide appropriate care and services to prevent harm.
Removal Plan
- Full facility skin assessment sweep completed by facility nursing leadership.
- Wound Care Consultant rounded for residents with areas of wound concerns.
- Full facility Braden Scale Sweep completed by nursing leadership.
- Interventions put in place based on Braden scale score.
- All care plans for residents with any skin concerns reviewed for appropriate interventions and updated.
- Review each resident's nutrition, appetites, weights, blood sugar, hydration by nursing leadership to ensure appropriate interventions are in place.
- Inventory of all mattresses and cushions that residents utilize and identify the stages for each.
- Order an Alternating Air Mattress that supports up to a Stage IV wound.
- Obtain mattress and cushion information from manufacturer or supplier to ensure they meet the correct needs of the residents.
- Hydration assessments on residents identified for Pressure Ulcers.
- Training for RNs and LPNs initiated.
- Implement weekly Wound Rounds to be completed on Tuesday Mornings.
- Update Admission and Re-admission checklist to clarify expectations upon admission for the Skin assessment, Braden scale, and interventions implemented in the baseline care plan.
- Implement checklist for nursing to use when a new skin concern is identified.
- Implement new documentation for meals, fluids, and snacks.
- Implement provider and resident representative being updated weekly after wound rounds with current wound measurements and wound assessment.
- Update policy and procedures related to skin, wounds, Braden scales, and repositioning.
- Conduct audits daily for residents with pressure injuries.
- QAPI will review all residents with wounds monthly.
- QA will review all residents with wounds quarterly and review/update skin care policies as needed.
- Facility Assessment will be updated related to any wound resident care requirements.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with diabetes, heart failure, muscle weakness, severe cognitive impairment, incontinence, and limited mobility was identified as at risk for pressure ulcers, with care plans calling for turning/repositioning, use of a pressure-reducing device, and extensive staff assistance for ADLs. Despite these documented risks and interventions, the resident, who preferred to remain in a recliner or wheelchair and became less mobile after a foot fracture requiring a walking boot, developed a facility-acquired Stage 2 pressure ulcer on the buttocks. Wound assessments showed the ulcer’s presence and progression over time, indicating that timely and effective preventive measures were not implemented in accordance with the facility’s wound assessment and prevention policy.
A resident receiving palliative care with multiple comorbidities, including CHF and acute kidney disease, had physician orders for specific left heel wound care that were not followed when an RN omitted the ordered normal-saline–moistened gauze and instead applied only a clean dry dressing. The same resident’s wound vac was discontinued per provider order, and prior wound care orders were stopped, but no new wound treatment was implemented for several days, with the new left heel dressing regimen not started until four days later. The ADON reported difficulty communicating with the hospice agency to clarify wound care orders and acknowledged not seeking a temporary order from the facility’s medical director.
Surveyors found that the facility failed to provide timely and appropriate pressure ulcer assessment, treatment, and prevention for two residents. One resident was admitted with a stage 3 buttock ulcer, but the Braden assessment was left incomplete, no pressure-ulcer risk care plan was initiated on admission, and wound consultant recommendations (including Medi-honey and preventive measures) were not promptly entered as physician orders or care-planned; weekly wound measurements were also missing while the ulcer enlarged and was described as stalled. Another resident with a right humerus fracture and sling was initially assessed as not at risk for pressure injuries, with no documentation of limited mobility or sling use, no early orders for a sling or skin checks under it, and a care plan that did not specify monitoring skin under the sling. Skin checks were inconsistently documented, and only after the family raised concerns was a large open elbow pressure injury and additional ankle/heel pressure areas identified, without comprehensive initial wound measurements, repeat Braden scoring, or updated care plans to address the new pressure areas and device-related skin monitoring.
Two residents at high risk for pressure ulcers did not receive consistent, individualized prevention and treatment measures, resulting in the development and worsening of multiple pressure injuries. One resident with severe cognitive impairment and high Braden risk, fully dependent on staff for mobility and hygiene, was repeatedly observed in bed with the head of bed elevated and sliding down, without documented q2h repositioning, individualized pressure-relief interventions, or consistent use of barrier cream, and CNAs and restorative staff were unaware of specific pressure-prevention measures for her. Another resident with multiple comorbidities, prior healed pressure ulcers, and a high Braden score developed recurrent stage II and III pressure ulcers to the coccyx and gluteal fold, a left heel DTI, and a left lateral leg stage II ulcer; ordered wound treatments were not documented as completed on at least one ordered date, he was not on a defined turning schedule despite being largely bedfast, and heel offloading and use of heel boots were inconsistently implemented and documented. In both cases, staff interviews and record review showed that facility practices did not consistently align with the facility’s own skin and pressure injury prevention policy requiring q2h repositioning, appropriate support surfaces, and systematic offloading for bedfast residents.
Surveyors found that the facility failed to provide pressure ulcer care consistent with professional standards for three residents. One resident with hemiplegia and vascular dementia had a sacral wound that was omitted from the care plan and repeatedly left off weekly skin assessments, while heel wounds were documented without consistent measurements or staging and ordered treatments were not always recorded as given. A second resident with multiple comorbidities developed a sacral wound that progressed from MASD to an unstageable and then Stage 4 pressure injury with surgical debridement, yet the care plan was not updated to reflect the active pressure ulcer and specific interventions, and weekly skin assessments often lacked complete staging and measurements. A third resident with dementia and incontinence had an unstageable sacral ulcer and MASD, but weekly skin assessments were inconsistent, some ordered wound treatments and topical medications were not documented on the TAR, and nursing notes did not show that care was provided on those dates. Staff interviews revealed that the treatment nurse handled nearly all weekly skin assessments and wound care documentation, relied on the DON or wound physician for staging and measurements, and that facility policies requiring complete wound assessment and documentation were not consistently followed.
A resident with a stage 4 sacrococcygeal PI, Parkinson’s disease, hypertension, moderate cognitive impairment, and high assistance needs was not provided care consistent with the facility’s pressure injury prevention policy. Although the care plan included daily wound treatment and use of a LAL mattress, it lacked an individualized repositioning schedule and did not document education or reminders about repositioning. Facility documentation showed only that the resident was assisted to roll each shift, with no evidence of q2h turning in bed or of how often incontinence briefs were checked and changed. After the resident refused Foley catheter reinsertion, the IDT did not identify incontinence as a risk factor or add new wound-protective or moisture-preventive interventions, and the subsequent care plan for non-compliance omitted such measures. The TXN and DON confirmed that repositioning and protection of the wound from incontinence were not clearly implemented or reflected in the care plan, despite policy requirements.
Failure to Implement Timely Interventions to Prevent Facility-Acquired Pressure Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to initiate timely and adequate interventions to prevent the development and progression of a pressure ulcer for Resident 27, who was identified as at risk for pressure ulcer development. The resident had multiple diagnoses including diabetes mellitus, osteoarthritis, heart failure, and muscle weakness, and had a BIMS score of five indicating severely impaired cognition. Assessments documented that the resident required extensive assistance of one to two staff for bed mobility, personal hygiene, dressing, repositioning, and transfers, and that she had a urinary catheter for constant urinary retention and incontinence. The MDS and care plans identified the resident as at risk for skin impairment, with a history of refusing to lie down to relieve pressure from the buttocks, and indicated she was on a turning/repositioning program with nutritional or hydration interventions and a pressure-reducing device in her chair. A Braden Scale score of 16 further indicated risk for pressure ulcer development. Despite these identified risks and care plan directives, the resident developed a facility-acquired Stage 2 pressure ulcer on the left buttocks. Weekly wound assessments documented the presence and progression of an open area on the left buttocks, with measurements changing over time, including a lateral opening measuring 2.0 cm by 1.0 cm and later a left inner buttocks wound measuring 3.0 cm by 2.0 cm by 0.5 cm depth, and then 2.0 cm by 3.5 cm by 0.8 cm depth. The record noted that the resident became less mobile after sustaining a left 5th metatarsal fracture requiring a walking boot, and that she was incontinent and preferred to sit in a recliner and wheelchair rather than sleep in bed. The facility’s own Wound Assessment, Prevention and Treatment policy required timely skin assessments, Braden evaluations, and immediate implementation of plans to reduce pressure ulcer risk, but the development of a facility-acquired pressure ulcer under these known risk conditions demonstrated that timely preventive interventions were not effectively implemented.
Failure to Follow Wound Care Orders and Delay in Implementing New Treatment
Penalty
Summary
The deficiency involves the facility’s failure to provide pressure ulcer care according to physician orders and acceptable standards of practice for a resident with multiple diagnoses including palliative care encounter, congestive heart failure, and acute kidney disease. The resident had a physician order directing staff to cleanse the left heel with wound cleanser, apply normal-saline–moistened gauze, and cover with a dry dressing every shift. During an observation of wound care, an RN removed the soiled dressing, cleansed the wound with wound cleanser and gauze, patted the wound dry, applied skin prep, and applied a clean dry dressing, but did not apply the ordered normal-saline–moistened gauze. The RN later confirmed she performed the wrong treatment, and the ADON confirmed the wound care provided was not consistent with the physician’s order. The deficiency also includes a lapse in implementing new wound treatment orders after discontinuation of a wound vac on the resident’s left heel. The care plan documented the resident was at risk for skin impairment and pressure ulcers, and a physician order directed discontinuation of the wound vac and application of wet-to-dry dressing until further orders were received. A Nursing Progress Note documented discontinuation of prior wound care orders, including those related to the wound vac and associated procedures, but did not document that a new wound treatment was implemented at that time. The Treatment Administration Record showed that a new wound care order for the left heel—cleanse with wound cleanser, apply normal-saline–moistened gauze, and cover with a dry dressing every shift—was not implemented until four days after the wound vac was discontinued. The ADON stated the facility had difficulty communicating with the hospice agency to clarify the wound care order and acknowledged he did not think to obtain a temporary order from the facility’s medical director.
Failure to Provide Timely Pressure Ulcer Assessment, Treatment, and Prevention
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary pressure ulcer treatment and preventive services consistent with professional standards for two residents, and failure to prevent the development of new pressure ulcers for one of them. For one resident admitted with malnutrition, stroke, hypertension, and a stage 3 pressure ulcer on the left buttock, the Braden Scale assessment dated on admission was left blank and incomplete, and no pressure ulcer risk care plan was initiated upon admission. Although a wound consultant later documented a stage 3 left buttock ulcer with specific treatment recommendations, including cleansing, application of medical-grade honey, and preventive measures such as turning/repositioning and moisture management, these recommendations were not incorporated into the physician orders from the date of the consultant’s assessment through the following week. The clinical record also lacked evidence that the recommended preventive measures were care planned, and weekly wound measurements were missing for at least one week, despite documentation that the wound was larger and stalled during that period. The same resident’s care plan for pressure injuries was not initiated until 21 days after admission, even though the resident had an existing stage 3 pressure ulcer and was at risk due to comorbidities, immobility, and incontinence. Wound assessments over time showed that the left buttock ulcer increased in size and was described as stalled before later being documented as stable and improving. The wound consultant confirmed that there were no measurements documented for the week in early January and that the medi-honey treatment recommended in mid-December was not implemented. The Nursing Home Administrator and other administrative staff acknowledged that the facility failed to timely implement wound care treatment recommendations, failed to document weekly assessments for the stage 3 ulcer during the identified week, and failed to ensure Braden assessments were accurately completed and a pressure ulcer risk care plan was initiated in a timely manner. For a second resident, admitted with a right humerus fracture and other diagnoses including prior fractures, lung mass, muscle weakness, and hypertension, the admission nursing assessment documented no wound concerns and a Braden score of 19 (not at risk), and did not note the right humerus fracture, sling use, or limited mobility. Occupational therapy notes shortly after admission documented that the resident was non-weight bearing to the right arm and had impaired safety awareness, and the resident was observed with a sling, but there were no physician orders for a sling or for skin checks under and around the sling until later. The initial care plan identified risk for pressure ulcers due to decreased mobility and called for skin inspections every shift, but did not specify checking the skin under and around the sling. Skin check records showed intermittent documentation of “skin clear” and redness, with several days missing and no evidence of skin inspection every shift or specific checks under the sling. Subsequently, the resident’s son reported concerns about an open wound and the state of the sling, and staff then identified a large open pressure injury to the right elbow with reddened skin. Nursing notes from that time did not include a comprehensive assessment or wound measurements, and there was no additional Braden scale completed to reassess risk after the wounds were found. Within days, new deep tissue injuries and pressure areas were documented on the right ankle and heel, and later wound assessments by a consultant identified an unstageable right elbow pressure injury and additional pressure injuries on the right lateral heel and malleolus. Physician and PA documentation did not initially include wound measurements, and subsequent care plans after these pressure areas developed did not include the new pressure areas, a plan to check skin under and around the sling, or interventions related to healing the new pressure areas. Interviews with therapy, nursing, and wound care staff confirmed that the resident had a sling on admission, that expectations included checking skin under the sling, and that there were no early sling or skin-check orders, supporting the finding that the facility failed to prevent the development of pressure ulcers and to provide necessary treatment and services in accordance with professional standards. The surveyors concluded that the facility failed to ensure residents were provided necessary treatment and services to prevent and treat pressure ulcers, failed to complete accurate Braden assessments, failed to initiate timely care plans for pressure ulcer risk and existing wounds, failed to implement wound consultant treatment recommendations in a timely manner, and failed to conduct and document appropriate and consistent skin assessments, including under medical devices such as slings. These failures were cited under 28 Pa. Code: 201.29(a) Resident Rights, 28 Pa. Code 211.10(c)(d) Resident Care Policies, and 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.
Failure to Implement Individualized Pressure Ulcer Prevention and Treatment for High-Risk Residents
Penalty
Summary
The deficiency involves the facility’s failure to implement and individualize pressure ulcer prevention and care for two residents at high risk for skin breakdown, resulting in the development and worsening of multiple pressure injuries. One resident with severe cognitive impairment, diabetes, depression, and high Braden risk was dependent on staff for hygiene, repositioning, and transfers. On admission, she had no skin breakdown but was identified as at risk. Her care plan initially addressed potential skin impairment but did not include individualized repositioning or pressure-relief interventions beyond standard admission practices. Staff and leadership later acknowledged that the pressure ulcer prevention measures in place before her ulcer developed were standard for all admissions and not tailored to her specific risk factors. For this resident, documentation showed blanchable redness to the buttocks on a skin assessment, followed by identification of a facility-acquired abrasion to the left buttock and coccyx and additional undescribed areas on the backs of both thighs. The next day, the abrasion on the left buttock was documented as a stage II pressure ulcer, which later increased in size. Observations on multiple days showed the resident lying in bed on her back with the head of the bed elevated and her body bent at the chest, with staff acknowledging that this positioning increased the risk of shearing when she slid down in bed. Interviews revealed that she could not turn herself in bed and required staff assistance for repositioning, yet there was no documentation that she was turned every two hours, and the DON could not find evidence that she refused repositioning or barrier cream. CNAs and a restorative aide reported not knowing what pressure prevention interventions were in place for her, and one CNA left her in bed all day because the resident did not respond when asked if she needed anything, despite the resident’s inability to use the call light or reposition herself. The second resident had multiple serious medical conditions, including spinal stenosis, chronic kidney disease, atherosclerotic heart disease, dysphagia, and protein-calorie malnutrition, and was assessed as high risk for pressure ulcers on the Braden scale. He had a history of multiple pressure ulcers and other wounds that had previously healed, but subsequent skin evaluations documented recurrent redness and pressure areas, including a right gluteal fold pressure ulcer and coccyx involvement. Progress notes identified a bleeding open area under the right buttock, reclassification of a right gluteal fold lesion from MASD to a pressure ulcer, and later documentation of a large coccyx pressure area, a left lateral heel DTI, and a left lateral lower leg stage II pressure blister. His care plan listed multiple active pressure injuries and interventions such as an air mattress, pressure-redistributing cushions, wound treatments, and weekly wound monitoring. Despite these identified wounds and orders, the record showed that ordered wound care treatments were not documented as completed on at least one ordered date, and the DON agreed that if treatments were not signed as completed, they were not done, and that wounds would worsen if treatments were missed. Interviews with nursing leadership and the wound nurse indicated that the resident was not on a formal repositioning schedule, even though standard practice was to reposition residents every two hours, and that his heels were offloaded and repositioned only “as needed.” Staff reported that he often refused to get up in his wheelchair and refused heel lift boots, but refusals and effective approaches were not consistently documented. A PA-C stated she would expect preventative measures such as an air mattress to prevent recurrence of pressure ulcers, and the DON and RN unit manager confirmed that an air mattress was ordered only after multiple pressure injuries were documented. The facility’s own Skin and Pressure Injury Prevention Program policy required offering repositioning at least every two hours for bedfast residents, considering off-loading when the head of bed was elevated, and using special mattresses as indicated, but the documented care and staff interviews showed gaps between these policy requirements and the actual implementation of pressure ulcer prevention and treatment for this resident. Overall, for both residents, surveyors identified failures to consistently implement and document individualized pressure ulcer prevention measures such as scheduled repositioning, appropriate use of pressure-relieving surfaces, barrier creams, and heel offloading, as well as failures to ensure staff understood and followed care plan interventions. These failures occurred despite both residents being clearly identified as high risk for pressure injury and, in the second case, having a documented history of prior pressure ulcers and multiple active wounds.
Failure to Accurately Assess, Care Plan, and Treat Pressure Ulcers for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide pressure ulcer care consistent with professional standards, including accurate assessment, staging, measurement, care planning, and implementation of ordered treatments for multiple residents with pressure injuries. For one resident with hemiplegia, vascular dementia, incontinence, low body weight, and an admission Braden score indicating risk, the facility did not consistently identify and document all existing wounds. Her care plan listed only a left heel pressure wound and omitted a sacral wound. Weekly skin assessments from late January through March repeatedly failed to document the sacral wound after its initial identification, and heel wounds were inconsistently documented without required measurements or staging. On several dates, the weekly skin assessment was left blank or lacked measurements, despite physician documentation that the left heel wound progressed from Stage 3 to Stage 4 with increasing size. The treatment administration record (TAR) also showed missing documentation of ordered wound treatments to the sacrum and left heel on multiple dates, with no corresponding nursing notes indicating that care was provided. A second resident with hemiplegia, vascular dementia, diabetes, malnutrition, peripheral vascular disease, incontinence, and significant weight loss was identified as at risk for pressure ulcers but initially had no documented pressure wounds. Her care plan, last updated the previous year, addressed only potential for pressure ulcer development and other skin integrity risks, and did not reflect a current sacral pressure wound. However, physician orders and TAR entries showed daily treatment to a sacral wound, and weekly skin assessments documented a sacral wound beginning in mid-February. These assessments frequently lacked staging and, at times, lacked complete measurements. Over several weeks, documentation showed the sacral wound increasing in size and evolving from MASD to an unstageable wound and then to a Stage 4 pressure injury requiring surgical debridement of devitalized tissue, including subcutaneous tissue, muscle fascia, and tendon. Despite this progression and ongoing wound physician involvement, the resident’s care plan was not updated to reflect the current pressure injury and specific wound care interventions. A third resident with dementia, Alzheimer’s disease, muscle weakness, incontinence, and an initially non-risk Braden score that later declined to moderate risk had an unstageable sacral pressure ulcer present on admission and MASD. Her care plan included potential for pressure ulcer development, an unstageable sacral pressure ulcer related to immobility, and a wound infection requiring oral antibiotics. Physician orders directed weekly skin assessments and specific daily and evening wound treatments to the sacral area. However, the March TAR showed multiple dates where ordered sacral wound treatments and topical medication for left upper buttock redness were not documented as given, and nursing progress notes did not show that wound care was provided on those dates. Weekly skin assessments for this resident were inconsistent, with several assessments in early January documented as refused or limited, alternating between noting arm discoloration and no skin issues, and later assessments intermittently omitting the sacral wound or lacking measurements and staging. Wound physician notes documented an unstageable sacral pressure injury with rapid clinical decline and later a Stage 3 pressure injury that had increased in size, but these changes were not consistently mirrored in the facility’s weekly skin assessment documentation. Interviews with nursing staff and leadership further described systemic issues contributing to the deficiency. The treatment nurse stated she could not stage wounds and relied on the DON or wound physician for staging, and that she was responsible for updating care plans when new pressure injuries were identified, though she was unsure of the required timeframe. She also reported that she performed nearly all weekly skin assessments for approximately 96 residents Monday through Thursday, with no assessments scheduled on Fridays unless there was a new admission, and that wound measurements were typically taken only when the wound physician visited, after which she transferred his measurements into the weekly skin assessments. The DON and ADON indicated that the treatment nurse was responsible for all wound care planning, weekly skin assessments, and ensuring documentation, and acknowledged that missing or inconsistent wound measurements and documentation on weekly skin assessments would prevent the facility from determining whether wounds were improving or worsening. Facility policies required full assessment and documentation of pressure ulcers, including location, stage, length, width, depth, exudate, and necrotic tissue, as well as complete wound care documentation, but the records for these three residents showed repeated omissions and inconsistencies in assessment, staging, measurement, care planning, and documentation of ordered treatments.
Failure to Implement Repositioning and Moisture Management for Stage 4 Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide care and services to prevent deterioration of a stage 4 sacrococcygeal pressure injury in accordance with its own pressure injury prevention policy. The resident had a documented stage 4 PI of the sacral region, Parkinson’s disease, hypertension, moderate cognitive impairment, and required substantial/maximal assistance with toileting hygiene, rolling, and transfers. A Braden Scale score of 16 identified the resident as at risk for pressure injury. The Skilled Evaluation Nurse note indicated a pressure-reducing device for the bed but did not indicate that the resident was to be turned and repositioned every two hours. The resident’s care plan for the stage 4 sacrococcyx PI included cleansing with normal saline, applying Santyl ointment, and covering with dry and foam dressings daily, as well as providing pressure relief and a low air loss mattress to support body alignment and position. However, the care plan did not include an individualized repositioning schedule or education and reminders about the importance of repositioning. Documentation from the facility’s records showed that the resident was assisted to roll left and right every shift, but there was no documentation that the resident was turned and repositioned every two hours while in bed, nor was there documentation of the frequency of incontinence brief checks and changes after each episode. After the resident refused reinsertion of a Foley catheter, nursing progress notes documented the refusal but the IDT wound management conference record did not identify incontinence as a risk factor affecting healing of the stage 4 PI and did not document any new recommendations following the catheter refusal. A subsequent care plan addressing the resident’s potential for worsening condition related to non-compliance with Foley catheter reinsertion did not include wound protective measures or moisture-preventive interventions. During interviews, the treatment nurse acknowledged uncertainty about how often the resident was turned/repositioned or how frequently incontinence briefs were checked and changed, and confirmed that the care plan did not include measures to ensure turning at least every two hours or effective measures to protect the sacrococcyx PI. The DON stated that staff were supposed to ensure turning at least every two hours and protection of the wound dressing from incontinence, and that the IDT did not address this risk, so the care plan was not revised, despite facility policy requiring prompt cleaning after incontinence, use of barrier products, individualized repositioning schedules, and ongoing review of interventions for effectiveness.
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.
