F0686

D

Failure to Implement Pressure Ulcer Prevention and Off‑Loading Interventions

Flint, Michigan Survey Completed on 01-15-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to implement and operationalize its pressure ulcer care policies for two residents, resulting in inaccurate documentation and failure to carry out ordered interventions. For one resident with a right heel pressure ulcer present on admission, surveyors repeatedly observed the resident lying in bed on their back with both heels directly on the mattress. Heel boots ordered for off‑loading were seen unused on a table, and there were no pillows or other positioning devices in the room to float the heels. The resident reported having a pressure ulcer on the right heel and stated staff did not assist with positioning the heels off the mattress. Despite this, electronic documentation over the prior 30 days showed the task “Float heels (as tolerated) while in bed” marked as completed (“Yes”) 77 times, including multiple entries on the days when surveyors directly observed the heels not floated.

Record review for this resident showed inconsistent and evolving documentation of the right heel wound, including descriptions as a stage I pressure injury, a blister, and later an unstageable pressure injury with 100% slough and serous drainage. An external wound care provider documented an open right posterior heel wound likely related to pressure and recommended Q2H turning/repositioning and heel off‑loading with boots or floating. During a wound care observation, the nurse removed a dressing from the right heel and a wound with black necrotic tissue over a bony prominence, surrounded by red/purple tissue approximately the size of a half dollar, was observed. After the dressing change, the resident was again left with heels directly on the mattress, and no pillows were present for off‑loading. When questioned, the assigned RN acknowledged that the resident’s heels had not been floated and that attempts to float the heels had not been made when no positioning device was available, despite documentation indicating otherwise.

For a second resident with an unstageable pressure ulcer on the left gluteal area being treated with Santyl, the facility also failed to follow care plan interventions for turning and repositioning. This resident was non‑ambulatory, required assistance with ADLs, and had care plan interventions including encouragement to turn and reposition every two hours and assistance by two staff for bed mobility. The resident reported having a wound on the buttocks and pain in the “backside,” rating the pain as four out of ten, and stated they could not reposition themselves. The resident indicated staff turned and repositioned them only when they needed to be changed, which they described as a couple of times a day. A family member present stated the resident had not moved since their arrival several hours earlier. Subsequent observations found the resident in bed on their back and later slightly on their right side, with the resident unable to recall how long they had been in that position and reporting ongoing pain and that morning care had not yet been provided.

During a wound care observation for this second resident, staff removed the dressing from the left buttocks and revealed an area of black necrotic tissue approximately the size of a nickel with bright red surrounding tissue, and a separate nearby area about the size of a dime with a white wound bed. Immediately after the dressing change, the resident was transferred by mechanical lift to a wheelchair. Hours later, the resident remained in the wheelchair, reporting feeling sore and tired, stating they had not returned to bed, had not been repositioned in the wheelchair, and that their brief had not been checked or changed since being placed in the chair. The LPN confirmed the resident had been up in the wheelchair continuously since the wound care. The facility’s own skin management policy required skin assessments, weekly wound rounds, and interventions such as turning/repositioning, heel off‑loading, and scheduled time out of bed, but the observations and interviews showed these interventions were not consistently implemented for the two residents with pressure ulcers.