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F0686
J

Widespread Failures in Pressure Ulcer Prevention, Assessment, and Infection Control

Danville, Illinois Survey Completed on 10-02-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Multiple failures in care were identified for residents with pressure ulcers, including a lack of timely repositioning, incomplete and delayed skin assessments, and failure to update care plans with appropriate interventions. One resident, who was severely cognitively impaired and completely dependent on staff for all activities of daily living, developed 18 separate facility-acquired pressure ulcers over several months, including multiple Stage 4 and Stage 2 ulcers. Staff did not consistently follow physician orders for wound care, did not provide wound supplements as ordered, and failed to obtain laboratory tests in a timely manner. Observations revealed that the resident was not repositioned or provided incontinence care for extended periods, and care plans did not reflect all current wounds or necessary interventions. During wound care procedures, staff failed to prevent cross-contamination. For example, a nurse's gown made contact with an open Stage 4 pressure ulcer, and the nurse continued the dressing change without changing gloves or cleansing the wound again. In another instance, a resident's sacral wound came into contact with a contaminated incontinence brief, and the wound was not re-cleansed before a new dressing was applied. Staff admitted to being aware of these breaches in infection control but did not take corrective action at the time. Additionally, wound care was not always performed according to the most current physician orders, as staff found the orders confusing and did not consistently review updated wound progress notes. Other residents also experienced deficiencies in care. One resident developed a Stage 4 pressure ulcer on the left ischium and a Stage 2 ulcer on the coccyx, both acquired in the facility. Staff failed to identify and assess new wounds promptly, did not transcribe or provide ordered wound supplements and dressing changes, and did not update care plans with wound interventions. In another case, a resident with a Stage 4 pressure ulcer on the right great toe did not receive proper infection control during dressing changes, and a risk management assessment was not completed. These failures resulted in wound infections requiring antibiotic treatment and contact isolation.

Removal Plan

  • The facility reviewed all resident wound progress notes and Physician Order Sheets (POS) and updated them as needed prior to the resident's next scheduled treatment change.
  • Director of Nurses (DON) and Regional Clinical Nurse Consultant oversee this.
  • All licensed nurses were educated on the facility Physician Ordering process, including entering and processing policy.
  • All licensed nurses were educated on the facility documentation policy using an Electronic Medical Record (EMR), including timeliness, accuracy, relevance, and completeness of entries.
  • The facility developed and implemented a plan to ensure staff who identify residents acquiring new pressure sores document the sore assessment, make the appropriate notifications, reassess the newly acquired wound within 24 hours, and obtain consent for the resident to see Wound Physician.
  • The facility will ensure the direct care nurse reviews the Treatment Administration Record (TAR) prior to conducting wound care.
  • The facility developed a process to ensure physician orders for laboratory tests are entered in the resident EMR timely.
  • The facility has a process to ensure staff develop and provide interventions to prevent pressure ulcers from forming and/or worsening.
  • All licensed nurses were provided education on the facility Pressure Injury and Skin Condition Assessment policy.
  • All licensed nurses and CNAs were educated on the facility Pressure Ulcer Prevention Policy.
  • All CNAs were provided education on how to access wound care prevention interventions.
  • All licensed nurses and CNAs were educated on the facility Physician-Family Notification Policy.
  • All licensed nurses and CNAs were educated on the facility Basic Care Plan Policy.
  • All licensed nurses and CNAs were educated on the facility Resident Round guidelines.
  • The facility Dietary Manager was educated on following physician diet orders, including ensuring residents with wound supplements were served the correct diet.
  • All licensed nurses, CNAs, and dietary staff were educated on the facility Diet Orders guidelines.
  • All licensed nurses were educated on the facility admission of Resident guidelines.
  • The facility Care Plan Coordinator was educated on the facility Comprehensive Care Plan review.
  • The facility Interdisciplinary Team (IDT) members were educated on the facility Comprehensive Care Plan policy.
  • The facility held a Quality Assurance Performance Improvement (QAPI) meeting.
  • The facility conducted a facility-wide audit of all resident wound care plans.
  • The facility initiated audits to ensure residents with pressure ulcers have correct physician orders in the EMR, completed assessments, revised care plans, reviewed wound physician progress notes, and reviewed and updated the resident Physician Order Set (POS).
  • The facility created a Quality Assurance Tool to verify these practices are occurring.
  • The facility presented an abatement plan to remove the immediacy.
See complete original report
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