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F0686
J

Failure to Prevent and Manage Pressure Ulcer Resulting in Severe Harm

Perrysburg, Ohio Survey Completed on 12-23-2025

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

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.
See complete original report
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