F0686

K

Failure to Assess and Manage Pressure Ulcers Leading to Severe Wound Infection

Windom, Minnesota Survey Completed on 01-27-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to identify, comprehensively assess, monitor, and implement effective interventions to prevent and manage pressure ulcers for multiple residents, with Immediate Jeopardy for one resident. One resident with paraplegia, diabetes, obesity, an indwelling catheter, and an ostomy was dependent for lower body care and transfers and was identified as at risk for pressure ulcers. On admission, the resident’s right heel wound was noted but not staged or fully described despite form instructions to document blanchability, size, color, odor, and discharge. The initial care plan did not include a skin integrity problem or the right heel wound, and subsequent skin checks failed to mention the heel wound. For an extended period after admission and readmission, the care plan was not revised to reflect existing and newly identified skin issues, including sacral redness, and pressure-relieving interventions were delayed or incompletely incorporated into the care plan.

As time progressed, the resident developed multiple additional areas of impaired skin integrity, including buttocks, coccyx/sacrum, urinary meatus, and foot wounds. Wound clinic records showed comprehensive staging and measurements of the right heel and urinary meatus pressure ulcers and later buttock shearing injuries, while facility documentation (RN wound assessments, skin observations, and progress notes) was inconsistent and often lacked measurements, staging, wound type, and detailed descriptions. New wounds and changes in condition, such as buttock shearing and coccyx pressure areas, were not consistently or comprehensively assessed, and physician notification for new or worsening wounds was not evident for several documented changes. The care plan was not timely updated to include wound clinic recommendations, such as catheter and brief management for the urinary meatus ulcer and interventions to prevent recurrent shearing injuries to the buttocks.

In the weeks leading up to the Immediate Jeopardy period, documentation of the resident’s buttock and coccyx wounds remained inconsistent, with alternating descriptions of coccyx versus buttock involvement and characterizations as shearing or pressure sores, without comprehensive wound assessments or clear identification of wound type. Skin observations and wound data collections around the end of the year showed black and blue tissue on the buttocks and new left lateral foot involvement, yet there was no documented physician notification or change in treatment orders for these developments. Wounds were not measured until early January, at which time large buttock wounds with significant eschar and slough, macerated and erythematous margins, and drainage were finally documented. Interviews with nursing staff revealed reliance on a clinical care lead RN to measure wounds and obtain orders, acknowledgment that wounds had not been measured for weeks, and use of treatments such as hydrofera blue and cleansing with soap and water or wet wipes without clear physician authorization or articulated evidence-based rationale.

Throughout this period, the resident was not placed on a formal turning and repositioning schedule despite being at risk for pressure ulcers and dependent for repositioning. Staff and interdisciplinary team notes repeatedly referenced the resident’s refusals to get out of bed or reposition, but these notes were often verbatim over multiple entries and did not reflect new assessments or individualized interventions to address refusals. Nursing assistants reported that the resident rarely refused care and would usually accept care when re-approached, while a nurse later stated the resident had not received education on the risks of not repositioning prior to hospitalization. The clinical care lead RN stated that shearing was not a form of pressure, that the resident’s discolored buttocks were “always” monitored, and that larger protective dressings such as Mepilex were sometimes not used due to size or payor concerns, leading to use of ABD pads instead. By the time the resident was evaluated at the wound clinic in January, the buttock and foot wounds were classified as unstageable and stage 3 pressure ulcers, with the gluteal wound described as very advanced and infected, and subsequent hospital records documented sacral decubitus ulcer with osteomyelitis and cellulitis.

Additional observations after the resident’s return from the hospital showed ongoing gaps in wound management and monitoring. Nursing staff could not initially locate dressing change orders, and the resident reported that no care had been provided to his heels over the weekend and that wedges for repositioning were only used if he requested them. On examination, facility leadership identified a dark, non-blanching area on the right lateral foot that was questioned as an unstageable pressure ulcer or suspected deep tissue injury, while the clinical care lead RN initially characterized it as a blister and a diabetic wound. Toenails pressing into adjacent toes and causing skin indentations were discovered only during surveyor observation, and improvised measures such as placing gauze between toes were initiated at that time. These documented inactions and inconsistent assessments, monitoring, and interventions for existing and developing wounds contributed to the progression of the resident’s buttock wound to a severe, infected pressure injury requiring hospitalization for osteomyelitis, cellulitis, and soft tissue infection.