F0686

G

Failure to Assess, Care Plan, and Treat Leading to Development of Stage 3 Pressure Ulcer

Montebello, California Survey Completed on 01-20-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide appropriate pressure ulcer prevention and treatment for a newly admitted resident who was admitted without pressure ulcers and had paraplegia, muscle weakness, and lack of coordination. The admission record and history and physical documented no pressure ulcers on admission, and therapy evaluations showed the resident required maximal assistance for bed mobility, activities, and personal hygiene. Despite this high-risk profile, the Braden Scale for Predicting Pressure Ulcer Risk completed on the admission date was left incomplete, with no scoring or staff signature, and the resident’s risk level for pressure ulcer development was not determined as required by the facility’s Skin Integrity Management policy. From admission through several days, weekly body checks documented no skin breakdown, and the interdisciplinary care conference did not identify or address any pressure ulcer risk or presence.

From admission through more than a week, the facility did not develop a comprehensive care plan with specific interventions to prevent pressure ulcers for this resident. No care plan was in place to address pressure ulcer prevention or to incorporate interventions such as repositioning, use of a low air loss mattress, or incontinence management, despite the resident’s dependence on staff for turning and repositioning. During this period, the resident remained on a regular mattress rather than a low air loss mattress. On one day, the resident’s family member assisted a CNA with an incontinent brief change and observed new redness and open skin on the buttocks/sacrococcyx area that had not been present previously. The CNA reported that the resident had refused an earlier brief change, did not know how long the brief had been soiled, and did not directly observe the buttock area during the change because she was holding the resident while the family member performed the cleaning.

Later that same day, an LVN was informed by the family member about the skin issue and initially had not yet assessed the resident’s skin or notified the physician. After assessing the resident, the LVN documented a change in condition note indicating a deep tissue injury on the left buttock and a Stage 3 pressure ulcer with surrounding deep tissue injury on the sacrococcyx and reported notifying the physician with a recommendation for wound consultation and treatment orders. However, there was no documentation of physician wound treatment orders on that date, and the wound was not measured for length, width, depth, or other characteristics at the time of initial identification. Physician orders for wound treatment were documented the following day, directing cleansing with normal saline, application of Medi-Honey and barrier cream to the sacrococcyx Stage 3 ulcer, and zinc oxide to the left buttock DTI. The MAR/TAR showed no evidence that any initial wound or skin treatments were provided on the day the Stage 3 ulcer was identified, and no evidence that the ordered treatments were performed the following day. The LVN later stated she had received a telephone order for treatment but did not enter it into the electronic MAR/TAR because she did not know how, and she did not perform the initial wound treatments, assuming treatment nurses would do so.

Subsequent wound assessment by a physician assistant documented a Stage 3 pressure ulcer on the sacrococcyx with purple discoloration, measuring 5 cm by 7 cm by 0.2 cm, with light serosanguineous drainage, and noted that surgical debridement was performed. Later observations confirmed the resident continued to lie in bed without a low air loss mattress, even after the pressure ulcer was identified. A Braden Scale completed several days after ulcer identification showed the resident at moderate risk for pressure ulcer development. Nursing leadership and staff interviews confirmed that the Braden Scale had not been properly completed on admission, that no pressure ulcer prevention care plan had been developed from admission through the period when the ulcer developed, that the wound was not initially measured, and that ordered wound treatments were not provided on the first two days after identification. Staff also acknowledged that the resident required assistance of two people for turning and repositioning and that interventions such as repositioning, maintaining clean and dry skin, frequent incontinence care, and use of a low air loss mattress were standard preventive measures that were not implemented in a timely manner for this resident.

The report states that as a result of these deficient practices, the resident developed a deep tissue injury and a Stage 3 pressure ulcer on the sacrococcyx that required surgical debridement. The report further states that these deficient practices placed the resident at risk for infection, discomfort, and pain at the pressure ulcer site.