F0686

D

Failure to Provide Ordered Pressure Ulcer Treatments and Support Surfaces

Bloomfield Hills, Michigan Survey Completed on 01-14-2026

Penalty

No penalty information released

Summary

The facility failed to consistently implement ordered pressure ulcer treatments and preventive interventions for two residents with pressure injuries. For one resident with end stage renal disease, moderate protein-calorie malnutrition, dependence on dialysis, and prediabetes, surveyors observed on 1/13/26 that both feet were wrapped in gauze bandages dated 1/10, even though the Treatment Administration Record (TAR) showed the last documented treatments as completed on 1/9/26. Physician orders directed that the left heel deep tissue injury be cleansed with wound cleanser, treated with moist betadine gauze, covered with an ABD pad, and wrapped with kerlix, and that the right lateral ankle pressure ulcer be cleansed with wound cleanser, treated with Medihoney, covered with an ABD pad, and wrapped with kerlix, to be done on the night shift every Monday, Wednesday, and Friday. The January 2026 TAR showed that the ordered treatments for both the left heel and right lateral ankle were not completed on 1/12/26. When questioned, an LPN confirmed the dressings were dated 1/10, was unsure whose responsibility it was to complete the treatment, and could not explain why the 1/12/26 treatment was missed.

For another resident initially admitted with coronary heart disease, paranoid schizophrenia, type II diabetes, and a psychotic disorder, the clinical record and hospital documentation showed stage 3 pressure injuries of the coccyx, sacrum, and right buttock, with hospital instructions for a low air-loss specialty mattress, turning every two hours with wedges, and avoidance of adult briefs to limit moisture. The resident’s care plan included an alternating pressure mattress for pressure ulcers on the coccyx related to immobility. Hospital records from two separate stays documented stage 3 pressure injuries and specified use of a low air-loss mattress and q2h turning with positioning devices. During observation, the resident was found lying on their back in bed without a low air-loss mattress and without a wedge in the room or bed; the resident reported having a painful wound on their bottom and wounds on their heels and recalled a hospital stay for the wound. A nurse later confirmed the resident did not have a low air-loss mattress and stated the wound nurse had said the wound was stage 2 and did not require it. The wound nurse reported that low air-loss mattresses are generally used for stage 3 or above and acknowledged not reviewing the hospital discharge notes that documented stage 3 pressure injuries and the need for a low air-loss mattress.