Failure to Prevent and Manage Pressure Ulcer Resulting in Severe Harm
Summary
A deficiency occurred when the facility failed to provide timely assessment, ongoing monitoring, and appropriate interventions to prevent the development of a pressure ulcer for a resident with arterial and venous insufficiency who was identified as being at risk for pressure ulcers. The resident, who had severe cognitive impairment, immobility, and multiple comorbidities including diabetes and peripheral vascular disease, was found with an unstageable pressure ulcer on the right malleolus beneath an ankle monitoring device. There was no immediate wound assessment, no documentation of interventions regarding skin monitoring under the ankle monitor, and no evidence that the ankle monitor had been removed. The care plan did not include interventions to monitor the skin under the ankle monitor, and physician orders for the device did not specify skin checks. The wound was not accurately assessed or measured at the time it was discovered, and there was no documentation of family or physician notification. Following the identification of the pressure ulcer, there was a lack of timely and appropriate follow-up. The wound was not assessed by a physician on the day it was found, and wound care orders were not initiated until the following day. There was no documentation that the dietitian was notified or that the resident's nutritional status was reassessed in response to the new wound. As the wound deteriorated, recommended interventions such as the use of offloading heel boots were not documented as being implemented, and a wound culture was delayed. Orders for a vascular consult and laboratory testing were not promptly carried out, and there was no documentation that the physician was notified when intravenous fluids were not administered as ordered. The resident's wound continued to worsen, showing signs of infection, and ultimately required hospitalization. The resident was admitted to the hospital with a wound infection, septic arthritis, osteomyelitis, and severe hypoglycemia. Hospital records indicated the need for intravenous antibiotics, wound debridement, negative pressure wound therapy, and ultimately an above-the-knee amputation. Throughout the period leading up to hospitalization, there were multiple missed opportunities for timely intervention, monitoring, and communication among staff, providers, and family. Documentation was incomplete regarding the implementation of physician orders, wound care interventions, and monitoring of medical devices in contact with the resident's skin.
Removal Plan
- The Administrator immediately notified Physician #600, the Interim Medical Director.
- Unit Manager Licensed Practical Nurse (UMLPN) #108 conducted a thorough assessment on Resident #05 with no adverse effects noted.
- Registered Dietitian (RD) #100 completed a nutritional reassessment for Resident #05 and updated nutritional interventions by adding an additional nutritional supplement with all meals.
- The DON and UMLPN #108 reviewed Resident #05's wound care regimen to ensure it was updated per current physician orders.
- UMLPN #108 reviewed and evaluated Resident #05's medical devices (heel boot) for proper fit and skin protection measures.
- The DON implemented an enhanced turning and repositioning schedule for Resident #05 with documentation every two hours.
- The DON and ADON #114 reviewed Resident #05's pressure redistribution surfaces as indicated by the current risk assessment.
- The DON reviewed Resident #05's current skin care plan.
- The ADON #114 reviewed the Certified Nursing Assistant's charting documentation tasks to ensure accuracy.
- The DON/designee conducted audits for all residents to identify those at risk for pressure ulcer development, with focus on residents with ankle monitoring devices or other medical devices in contact with skin. Each identified at risk resident received immediate reassessment of current interventions and implementation of enhanced monitoring protocols.
- The DON identified one current resident (#51) with an ankle monitoring device and implemented skin monitoring checks each shift.
- The DON/designee identified 33 residents with medical devices and implemented enhanced orders for skin monitoring each shift.
- The DON/designee identified 10 residents with existing pressure ulcers or a history of pressure ulcers and implemented enhanced skin monitoring orders for nurses to complete visual skin checks on shower/bath day along with a daily comprehensive skin evaluation.
- The DON/designee identified 14 residents with vascular insufficiency or other circulatory conditions and implemented enhanced monitoring orders for nurses to complete visual skin checks on shower/bed bath day.
- The DON/designee identified 34 residents at moderate to high risk of skin breakdown and implemented enhanced monitoring orders for nurses to complete visual skin checks on shower/bed bath day.
- The DON, the Administrator, and ADON #114 conducted a root cause analysis identifying contributing factors including: insufficient knowledge of ankle monitoring skin monitoring protocols, lack of standardized skin inspection procedures for medical devices, insufficient communication systems for reporting skin changes, and absence of structured investigation process for new pressure ulcers.
- The DON/designee started education for all nurses and certified nursing assistants on pressure ulcer prevention, medical device skin safety, skin and wound assessment and documentation training with emphasis on timely reporting. Nurses were also re-educated on implementation of physician orders. Education to be completed.
- The Administrator and ADON #114 reeducated RD #100 on the position job description and the importance of reassessing residents with skin integrity changes.
- The DON/designee implemented enhanced monitoring orders for nurses to complete visual skin checks on all residents on their shower/bed bath day. All new admissions will be evaluated to determine if they qualify for this classification.
- The DON/designee implemented a standardized pressure ulcer investigation form and process.
- The DON/designee implemented weekly wound care rounds with wound team participation.
- The Administrator and the Quality Assurance Team reviewed policies on medical devices with skin integrity, lab procedures and policies, and clinical documentation.
- The Administrator and Medical Director implemented new best practices on A Guide to Device Skin Inspection.
- The DON reviewed the new admission checklist and updated it to include obtaining physician orders for skin monitoring for new admissions with medical devices. The new admission checklist was implemented and put into effect.
- The Administrator notified MD #602 of Immediate Jeopardy.
- UMLPN #108 conducted a thorough skin assessment on Resident #51 with no adverse effects noted.
- The Administrator reeducated UMLPN #102 on job duties, manager role, chart review, wound care, accurate order entry, complete investigation, and follow through on all job duties.
- The facility held an ad hoc Quality Assurance and Performance Improvement (QAPI) meeting with the Administrator, Infection Preventionist/ADON #114, UMLPN #108, UMLPN #102, and Medical Director.
- The Administrator and Medical Director reviewed policies for laboratory procedures and clinical documentation. The reviewed policies were acceptable with no changes needed.
- RD #100 reviewed all residents with skin integrity changes for nutritional intervention needs.
- The Administrator/designee educated all staff on new best practices A Guide to Device Skin Inspection. Education was completed.
- The Administrator/Designee educated all nurses on laboratory communication and documentation. Education was completed.
- The DON/designee conducted a review of all residents with medical devices for skin integrity documentation. Ongoing monitoring will occur daily for five days, then five residents weekly for four weeks, then two residents monthly for two months with a completion date.
- Unit Managers/designee performed an audit of physician order implementation timeframes on all residents with new orders or order changes. Audits will continue daily for five days, then audit five residents weekly for four weeks, then audit two residents monthly for two months with a completion date.
- The DON/designee will audit random resident medical records to ensure pressure ulcer prevention interventions and skin assessments are in place as ordered. Audits by the DON/designee will continue with five random resident medical records per week for one month, then two random resident records per week for two months with a completion date.
- The DON/designee will conduct weekly audits on wound dressing changes to ensure timely treatments on five random residents for four weeks, then for five random residents monthly for two months with a completion date.
- All systemic changes would be reviewed monthly for three months by the Quality Assurance (QA) Team. The DON/designee would report monitoring plan results to the QAPI committee monthly. The QAPI committee would monitor on an ongoing basis until sustained compliance was achieved with quarterly reviews to assess effectiveness and make necessary adjustment to the monitoring plan frequency on demonstrated compliance rates.
- Staff who were not educated would not be scheduled to work until the education was completed.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Failure to Reposition Resident With Stage 4 Pressure Ulcer: A resident with diabetes, CAD, HTN, and a stage 4 coccyx pressure ulcer was assessed as needing repositioning every 2 hours, but during prolonged observation staff did not offer repositioning while the resident remained in the same position in bed. The care plan called for turning and repositioning per tissue tolerance, but the bedside Kardex did not specify how often to reposition. When the issue was identified, RN and the ADON turned the resident and noted blanchable redness on the left buttocks and upper thigh.
Failure to provide ordered wound care for a resident with an unstageable pressure injury. The resident had chronic venous insufficiency and cellulitis, and the MDS showed the resident was cognitively intact with a pressure ulcer present on admission. A physician ordered xeroform gauze, Dakin's-soaked Kerlix packing, and an ABD pad twice daily, but observations found the wound without the ordered dressing and packing, then later with a soiled dressing and protruding packing. An LPN confirmed the dressing was soiled and undated/untimed, and the ADON acknowledged the findings.
Pressure ulcer prevention and wound care failures were identified for multiple residents. A resident with immobility and diabetes developed a facility-acquired sacral wound that progressed to an infected stage 4 ulcer requiring hospitalization and debridement, while surveyors observed missed wound vac documentation, stool-contaminated dressings, improper offloading, low air loss mattresses on static mode or incorrect weight settings, missing heel protectors, and a wheelchair resident without a pressure-relieving cushion.
Failure to Clean and Monitor a Pressure Injury: The facility failed to promote healing of a resident’s unstageable DTI to the right ischium. During wound care, the DON applied treatment without cleaning the wound first, despite staff and the wound physician stating that cleansing with saline or wound cleanser was appropriate. The record also lacked weekly nursing assessments documenting the wound’s location, stage, size, and description, and the facility relied on intermittent wound physician visits that were missed when the resident was at dialysis or out of the facility.
Failure to Measure and Offload a Right Heel Pressure Injury: A resident with DM, PVD, and a history of skin breakdown developed a right heel PI that was identified as a deep tissue injury and later progressed to stage 2 and then unstageable. Staff did not obtain wound measurements for about two weeks after discovery, several skin reviews lacked wound details, and surveyors observed the resident without ordered offloading boots in the recliner and wheelchair even though staff said the boots were to be worn at all times.
Failure to Prevent and Treat Pressure Ulcers: A resident with impaired cognition, total ADL dependence, incontinence, and high Braden risk developed worsening sacral and heel pressure injuries after staff did not consistently implement wound prevention measures or recognize the change in condition when sacral redness was first noted. The wound progressed to an infected stage IV sacral ulcer with foul odor, drainage, altered mental status, and hospital transfer; interviews and records also showed the wound was not consistently tracked or care planned, and the resident’s skin breakdown was not promptly escalated.
Failure to Reposition Resident With Stage 4 Pressure Ulcer
Penalty
Summary
Provide appropriate pressure ulcer care and prevent new ulcers from developing was not met for a resident with diabetes mellitus, coronary artery disease, hypertension, and a stage 4 coccyx pressure ulcer. The resident’s MDS identified dependence for lower-body dressing, transfers, toileting, and substantial to maximal assistance with rolling in bed. The care area assessment noted chronic pressure ulcers and diabetic foot ulcers, that the resident was often noncompliant with repositioning, and that he often refused to get out of bed. A tissue tolerance lying assessment identified existing wounds to the heels and coccyx and indicated the resident should be repositioned every two hours. The resident’s care plan included an air pressure mattress, nutritional supplements, and turning and repositioning per tissue tolerance, and the bedside Kardex stated the resident needed two staff for turns and boosts with a lift sheet, but it did not include how often to reposition him. During continuous observation from 7:06 a.m. to 9:51 a.m., the resident remained in the same position in bed while staff entered and exited the room for breakfast, lab work, snacks, and visits. No staff member offered to reposition him during that observation period, and he remained on his back with pillows supporting his sides and lower legs throughout the observation. When the surveyor informed the clinical manager that the resident had not been repositioned as care planned, RN-A and the ADON entered the room, checked the resident’s skin, and assisted him to turn onto his right side. RN-A noted redness on the left buttocks and upper thigh that was blanchable. During interviews, NA-C stated the usual practice was to assist the resident with repositioning every 2 to 3 hours, RN-A confirmed the tissue tolerance assessment called for repositioning every two hours, and the DON stated staff needed education to check on and reposition the resident following the care plan. The facility policy on pressure ulcers/injuries described pressure injuries as resulting from prolonged pressure or pressure with shear, but it lacked interventions for care and prevention of pressure ulcers.
Failure to Provide Ordered Wound Care for Pressure Injury
Penalty
Summary
The facility failed to ensure a resident with an unstageable pressure injury received the physician-ordered wound treatment needed to promote healing. Resident 5 was admitted with chronic peripheral venous insufficiency and cellulitis of the right lower leg, and the admission MDS dated June 10, 2026, documented that the resident was cognitively intact with a BIMS score of 15 and had one unstageable pressure ulcer present on admission. A physician order dated July 3, 2026, directed staff to apply xeroform gauze to the distal aspect of the right buttock wound, pack the wound with Kerlix gauze soaked in Dakin's solution, and secure the dressing with an ABD pad twice daily and as needed for soiled or dislodged dressings. During an observation on July 8, 2026, the wound was not covered with xeroform gauze and had no wound packing in place. During a second observation on July 9, 2026, the dressing was visibly soiled with a yellow-colored substance and the wound packing was protruding from the wound; an LPN confirmed the dressing was soiled and could not determine when it had last been changed because it was not dated or timed. The ADON later reviewed and acknowledged these findings.
Pressure ulcer prevention and wound care failures
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and to prevent new ulcers from developing for multiple residents, including residents with severe cognitive impairment, immobility, ventilator dependence, diabetes, and existing pressure injuries. The report states that staff failed to implement preventive interventions to maintain skin integrity, failed to ensure low air loss mattresses were on the correct settings while in use, failed to ensure multiple linen layers were not beneath residents on low air loss mattresses, failed to timely identify skin integrity impairments, failed to follow physician orders, and failed to document or administer prescribed treatments for 10 of 33 residents reviewed for pressure ulcers. For one resident with a facility-acquired sacral pressure ulcer, the record shows the resident was dependent on staff for rolling, had a stage 3 sacral wound identified as in-house acquired, and later developed a stage 4 sacral wound with odor, heavy purulent drainage, necrotic tissue, and signs of infection. The physician documented surgical excisional debridement, noted the wound decline over one week, and recommended transfer to the emergency department. The resident was hospitalized for an infected sacral wound and later records referenced systemic inflammatory response syndrome due to the infected sacral ulcer and a plan for surgical debridement. Survey observations also found the resident lying on a low air loss mattress without the sacral wound offloaded, with a wound vac canister full of blood nearby, and staff observed the wound vac dressing was not adhered and the dressing area was covered with stool. The report also describes multiple other residents whose pressure-relief measures were not maintained as ordered. One resident’s low air loss mattress was observed on static mode and set to an incorrect weight setting; another resident’s mattress was also on static mode; and several residents were observed with heels resting directly on the mattress or with only one heel protector boot available. A resident in a wheelchair was observed without a pressure-relieving cushion despite being at risk for pressure ulcers. For another resident, wound vac treatments were not documented on two scheduled days, and staff statements showed confusion about who was responsible for wound care and when wound vac orders should be carried out. The facility policy stated that residents should receive timely, individualized risk assessments, appropriate preventive interventions, and ongoing monitoring, and that skin changes should be addressed by licensed nurses, but the observations and record review showed these measures were not consistently implemented.
Failure to Clean and Monitor a Pressure Injury
Penalty
Summary
The facility failed to provide care and services to promote healing of a pressure injury for one resident with an unstageable deep tissue injury to the right ischium. The resident was cognitively intact on the most recent MDS, with a BIMS score of 14 out of 15, and the assessment documented one unstageable deep tissue injury that was not present on admission. The resident told surveyors that staff had been applying cream to a diaper rash wound on the buttocks and said it had been there for a while. During wound care observation, the DON performed treatment to the right ischium wound but did not clean the wound before applying the dressing. The DON stated she did not clean it because the physician order did not specify cleaning with anything, and said she would have used normal saline or wound cleanser if it had been ordered. The wound physician later stated that nursing staff should use their judgment for cleaning the pressure injury and could generally use wound cleanser or house stock saline. An RN also stated that she cleansed the wound with normal saline or wound cleanser because a wound should always be cleaned before treatment. The record also failed to show weekly monitoring of the wound with the required location, staging, sizing, and description. The wound physician notes showed assessments on some dates, but several visits were rescheduled because the resident was at dialysis or out of the facility, and one refusal was documented. The clinical record did not contain additional assessments or refusals to account for weekly monitoring. Facility policy required weekly evaluation and documentation of the pressure injury by a licensed nurse and/or practitioner, including wound location, stage, measurements, tissue type, drainage, surrounding tissue, pain, and interventions to promote healing.
Failure to Measure and Offload a Right Heel Pressure Injury
Penalty
Summary
The facility failed to ensure appropriate pressure injury care and failed to prevent worsening of a resident’s right heel wound. The resident had diagnoses including type 2 diabetes mellitus with diabetic chronic kidney disease and peripheral vascular disease, and had a history of pressure injuries and skin blistering. The resident’s Braden score was 13 on 1/29/25, indicating moderate risk for pressure injury development. The care plan included interventions for skin integrity, including offloading boots to both feet when in bed and in the recliner at all times, weekly skin checks, and monitoring for skin changes. On 4/1/26, the nurse practitioner identified a wound on the right heel and documented it as a deep tissue pressure injury with surrounding dark tissue and sanguineous drainage. Orders were entered for offloading boots and wound care. However, the first wound measurements were not obtained until 4/14/26, about two weeks after the wound was discovered. The weekly skin reviews on 4/2/26 and 4/9/26 documented the wound as open, but did not include wound measurements or wound characteristics. Later wound assessments showed progression from a stage 2 wound with granulation tissue and moderate drainage to an unstageable wound with eschar covering most of the wound bed. Survey observations on 6/29/26 showed the resident in a recliner and later in a wheelchair without the ordered offloading boots in place; the boots were observed sitting in the windowsill next to the bed. Staff interviews confirmed that the boots were expected to be worn at all times, including in bed, the recliner, and the wheelchair. Staff also stated that wound measurements should be completed weekly, but acknowledged that measurements were not started until the wound was classified as a pressure injury on 4/14/26. The record also showed a missed skin assessment on 6/23/26 and several wound entries without descriptions of wound bed characteristics.
Failure to Prevent and Treat Pressure Ulcers
Penalty
Summary
The facility failed to ensure a resident with multiple risk factors for skin breakdown received necessary wound prevention and treatment services after readmission and after a later change in condition. The resident had impaired cognition, was dependent for all ADLs, used a wheelchair, was incontinent of bowel and bladder, and was identified as at risk for pressure injuries. The record also showed a Braden score indicating moderate to high risk, with documentation that the resident was bedfast, had very moist skin, and required frequent linen changes and repositioning. The resident’s records showed that weekly skin observations and care planning did not consistently reflect the development and progression of the sacral wound. A skin observation documented redness on the sacrum, and later documentation described an open area with necrotic eschar, foul odor, drainage, and worsening deterioration. The wound was later documented as an unstageable pressure ulcer to the sacrum, with bilateral heel deep tissue injuries also identified. The record review also noted that the resident was not care planned for linens being changed every shift per the Braden Scale, and the initial tracking and trending wound list did not list the resident’s wounds even though the wounds were later found to have been acquired. The resident’s condition worsened to the point that the wound became infected, cultures identified multiple organisms, and the resident was transferred to the hospital with altered mental status and a stage IV sacral decubitus ulcer with infection. Interviews reflected that staff and the wound care nurse believed the wound could have been prevented with more frequent turning and incontinence care, and the wound care nurse stated the resident should have been sent out earlier when the sacral redness was first noted. The hospital physician stated the wound was severe, had exposed bone, had a horrible odor and drainage, and appeared to have been present long before the resident was sent out.
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