F0686

G

Failure to Prevent and Treat Facility-Acquired Pressure Injuries in At-Risk Residents

Matteson, Illinois Survey Completed on 01-23-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to prevent facility-acquired pressure injuries in residents at risk and to initiate appropriate wound treatment once new pressure ulcers were identified. One resident was admitted with multiple wounds and was assessed as being at moderate risk for pressure ulcers using the Braden Scale, with a score of 13. During the stay, this resident developed a new pressure ulcer on the rear left thigh that was documented with measurements but without staging or descriptive details of the wound. The wound nurse later confirmed that the documentation lacked staging and other required descriptors and, based on a photograph, would have staged the wound as unstageable.

For this same resident, review of the Treatment Administration Record and Physician Order Sheet with the wound nurse showed that there was no treatment order for the newly acquired rear left thigh pressure ulcer from the date it was first documented until the resident’s discharge. The wound nurse confirmed the absence of any treatment order, and the wound physician stated that it is important to have treatment for a wound as soon as it is identified, although he suggested that lack of an order did not necessarily mean no treatment was given. The facility’s own policies require that residents with pressure ulcers have a physician’s order for treatment, that wounds be described and documented weekly, and that licensed nurses document treatment on the Treatment Administration Record.

A second resident, admitted with intact skin and assessed as at risk for pressure injury with Braden scores of 17 on two separate assessments, developed three facility-acquired pressure injuries: a right heel wound initially documented as a diabetic ulcer and later classified as a Stage 4 pressure injury, an unstageable coccyx/sacrum pressure injury, and an unstageable rear left thigh (ischial) pressure injury described as a deep tissue injury. The wound care coordinator stated that CNAs are expected to check skin during care and report changes to nurses, who then refer to the wound care team, but confirmed there was no documentation of skin alterations prior to the identification of these pressure injuries. The wound physician’s notes documented the right heel as a Stage 4 pressure injury with nonviable tissue and necrosis, and the sacrum and left ischium wounds as unstageable due to necrosis or deep tissue injury.

Nursing staff reported that weekly head-to-toe skin assessments are performed, often during bathing or changing, and that any redness or skin changes should be promptly reported and documented for the wound care team to provide treatment orders. However, documentation review revealed no shower sheets or assessment records indicating that the second resident’s skin was assessed during showers or care before the wounds were discovered. The DON acknowledged a lapse in reporting skin conditions, stating that CNAs may have assumed nurses were already aware of the wounds and did not notify the wound care team, and agreed that a Stage 4 pressure ulcer could not develop overnight and that earlier signs should have been reported. Facility policies require daily skin checks, weekly documented skin checks, timely risk assessments, individualized care plans, and immediate treatment orders and wound descriptions for residents with pressure ulcers, but these processes were not followed for the residents involved, leading to the development and progression of multiple facility-acquired pressure injuries without timely identification and treatment.

The record for the second resident also showed that the right heel pressure injury became infected, with a wound culture positive for ESBL and subsequent IV antibiotic treatments ordered and administered for the infected heel wound. Despite nurse interviews describing routine and thorough skin assessments and prompt reporting expectations, there was no supporting documentation of early skin changes or interventions prior to the development of the Stage 4 and unstageable pressure injuries. The facility’s documented failures included not preventing facility-acquired pressure injuries in residents identified as at risk, not staging and fully describing a newly acquired pressure ulcer, not obtaining or documenting physician treatment orders for a new pressure ulcer, and not documenting or acting on early skin alterations as required by the facility’s pressure ulcer prevention and treatment policies.