F0686

F

Failure to Individualize Pressure Ulcer Care and Properly Use Support Surfaces

Santa Monica, California Survey Completed on 01-23-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide appropriate pressure ulcer care and to prevent the deterioration and development of pressure injuries for a resident with multiple existing pressure ulcers. The resident had diagnoses including Parkinson’s disease, encephalopathy, cognitive communication deficit, and multiple stage 4 pressure ulcers to the sacral region and both hips. An MDS indicated mild cognitive impairment, dependence on staff for ADLs, and the presence of three stage 4 pressure ulcers with risk for additional ulcers. Physician orders included use of a pressure-relieving mattress and turning and repositioning every two hours, with refusals to be documented. However, the facility did not consistently implement and document these interventions.

Care plans initiated for impaired skin integrity related to pressure injuries on the right buttocks and sacrum contained generic interventions such as “treatment as ordered” and did not specify individualized treatments, staging details, or clearly defined interventions beyond broad statements like monitoring skin and turning and repositioning. The treatment nurse stated that care plans for wounds and treatments were not updated with specific orders when wounds were reclassified or when new SBARs were generated, and that it was considered redundant to place actual treatment orders on the care plan. The treatment nurse also acknowledged that the same generic verbiage (“treatment as ordered”) was used for residents with various treatments ordered, and admitted that no SBAR was completed when a new right shoulder deep tissue injury (DTI) was discovered. A left shin DTI was discovered later, and the treatment nurse confirmed that a head-to-toe assessment could have identified this pressure ulcer earlier and prompted SBAR completion and physician and representative notification.

Documentation of turning and repositioning was incomplete over multiple days, with numerous time slots lacking evidence that the resident was repositioned every two hours as ordered. A CNA reported doing her best to reposition the resident but stated there were instances when the resident was found in the same position four hours later. The CNA also reported that the resident had pressure ulcers on the buttocks, right upper arm, and a more recent ulcer on the left lower leg. The wound care specialist explained that the low air loss (LAL) mattress is weight-based and must be set close to the resident’s weight, and that setting it to 400 lbs for a resident weighing 139 lbs would be like placing the resident on a table, potentially worsening current wounds or contributing to new pressure ulcers. The medical director stated that staff must notify a physician as soon as possible for changes in condition, urgently for new pressure ulcers, and that care plans must include clear, individualized goals, and also confirmed that placing a resident on a hardened surface for a prolonged period could worsen and cause more pressure ulcers. The facility’s own policies required comprehensive, individualized care plans and detailed assessment and documentation of pressure sores, including support surfaces, which were not fully followed in this case.

Additional interviews and record reviews further highlighted lapses in wound care delivery and communication. The treatment nurse initially stated he had not performed the resident’s wound care on a specific date, then later recalled that he had completed the treatments but was unable to describe the shin pressure injury and could not clearly describe what a DTI looked like. He also confirmed that lack of treatment to the left shin could result in wound deterioration, infection, sepsis, organ failure, and death. An LVN who covered as treatment nurse on one of the dates stated she had not completed the resident’s treatment because she was assigned to a different station, which was supposed to be covered by the treatment nurse. The facility’s policies on care planning and pressure ulcer/skin breakdown required comprehensive care plans prepared by the IDT and detailed assessment and documentation of pressure sores, including current treatments and support surfaces, but the practices described in the report did not align with these requirements, contributing to worsening existing pressure ulcers and the development of facility-acquired pressure ulcers for this resident.