F0726

D

Failure to Competently Assess and Report New Pressure Ulcers and Manage 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 ensure that licensed nurses had the competencies and skills to adequately assess, describe, and report a new pressure ulcer for a resident with multiple existing pressure injuries and significant comorbidities. The resident had Parkinson’s disease, encephalopathy, a cognitive communication deficit, and multiple stage 4 pressure ulcers to the sacrum and both hips, and was mostly dependent on staff for ADLs. Care plans initiated for impaired skin integrity included generic interventions such as “treatment as ordered” and did not specify the actual wound treatments, staging details, or individualized interventions beyond broad statements. The resident’s MDS documented three stage 4 pressure ulcers and risk for additional PUs, and physician orders included specific wound care treatments and turning/repositioning every two hours, but these details were not clearly integrated into individualized care plans.

Surveyors’ review of CNA documentation for turning and repositioning showed numerous time slots over multiple days with no documented evidence that the resident was repositioned as ordered. A CNA reported that she tried to reposition the resident but sometimes found the resident in the same position four hours later. The resident was observed with adhesive dressings on the right upper arm and left shin; the CNA stated the resident had pressure ulcers to the buttocks, right upper arm, and a more recent one to the left lower leg. The treatment nurse later stated the resident was being treated for four pressure ulcers (sacrum, left posterior trochanter, right buttocks, and right shoulder DTPI) but was initially unable to state what was under the dressings to the right upper arm and left shin, incorrectly believing those areas had healed PUs. The treatment nurse also acknowledged that head-to-toe skin assessments are supposed to be done and that SBARs and care plans must be updated for new or reclassified wounds, but admitted that treatments on care plans were documented only as “treatment as ordered” and that this same generic wording was used for multiple residents.

An SBAR note dated 1/23/2026 documented a pressure injury to the left shin and right shoulder, with concern for an unstageable pressure injury on the shin and a DTPI/UTI-type injury on the shoulder, and indicated the development of pressure injury due to pillow placement. During wound care observation, the room had a foul odor, and the right upper arm ulcer was covered in black-brown jelly-like eschar, while the left shin ulcer measured approximately 7 cm by 3 cm with hard yellow-grey slough and a red halo, with no drainage. The family member reported they only learned of the left shin pressure ulcer a few days earlier during a visit and that the facility had not informed them of this new wound. The treatment nurse admitted that no SBAR had been completed when the right shoulder DTPI was discovered and that the left shin DTI had just been discovered that morning, acknowledging that a head-to-toe assessment could have identified it earlier and prompted SBAR completion and physician and representative notification. The treatment nurse initially stated he had not done the resident’s wound care on 1/21/2026, later recalled that he had, and was still unable to accurately describe the shin wound or what a DTPI looked like.

Additional findings showed that the resident’s low air loss (LAL) mattress was not set according to the resident’s weight. The resident weighed 139 lbs, but the mattress was set over the maximum of 400 lbs. The DON stated that mattresses were usually set at 400 lbs to ensure tubes were inflated and should not be set lower than 152 lbs, but could not explain why, while the wound care specialist and an LVN stated that LAL mattresses are weight-based and must be set as close to the resident’s weight as possible, and that incorrect settings could lead to more or worsening pressure injuries. The facility’s pressure ulcer/skin breakdown policy required nurses to perform and document a full assessment of pressure sores, including location, stage, measurements, exudate or necrotic tissue, pain, mobility status, current treatments including support surfaces, and all active diagnoses. The survey findings showed that licensed nursing staff did not consistently perform or document comprehensive assessments, did not accurately describe and stage new wounds, did not promptly complete SBARs or notify the physician and resident representative of new pressure injuries, and did not ensure that support surfaces such as the LAL mattress were properly set, all contributing to a delay in treatment for the resident’s new unstageable pressure injury to the left shin, which the report states could have resulted in further deterioration, infection, sepsis, organ failure, and/or death.