F0686

G

Failure to Provide Timely Pressure Ulcer Prevention, Assessment, and Wound Management for Two Residents

Papillion, Nebraska Survey Completed on 01-20-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to evaluate, monitor, and implement appropriate interventions for pressure ulcer prevention and wound care for two residents, despite facility policy requiring comprehensive skin assessments, staging by licensed staff, and routine wound measurements documented on wound progress forms. The facility’s Skin Integrity, Wound, Ulcer Assessment Prevention Treatment Documentation Policy dated 02-11-2021 states that all team members are responsible for preventing and treating altered skin integrity, that wounds must be measured in three dimensions upon identification and at admission, and that measurements must be completed routinely and documented for all impaired skin integrity issues. For Resident 3, who was admitted with intact skin, quadriplegia, multiple sclerosis, moderate cognitive impairment, total dependence for ADLs, and a Braden score of 13 indicating moderate risk, the baseline care plan identified risk for skin breakdown and called for repositioning, nutritional support, and notification of the PCP for skin changes, but did not initially include pressure-reducing surfaces for the bed or wheelchair.

For Resident 3, the record showed no weekly skin evaluation between admission and 05-23-2025, a 14‑day gap, despite the resident’s identified risk. Interventions for pressure ulcer prevention, including a pressure reduction mattress and wheelchair cushion, were not implemented until 05-21-2025, after a stage 2 pressure ulcer to the left buttock had already developed. The initial wound evaluation for this ulcer was not conducted, and early documentation lacked wound measurements and descriptions. Progress notes later documented a stage 2 pressure ulcer to the left buttock and an additional pressure ulcer to the left heel, again without measurements. By late July, documentation showed a new stage 3 pressure ulcer to the right buttock with full-thickness skin loss and tunneling, with measurements recorded on 07-28-2025, but the comprehensive care plan contained no new interventions specific to this stage 3 ulcer. During observation of wound care, surveyors noted a right gluteal wound with tunneling and drainage, and the ADON acknowledged that causal factors for the right buttock ulcer had not been identified. The DON confirmed that Resident 3 had two separate pressure ulcers, one on each buttock.

Additional deficiencies for Resident 3 involved the use and management of an air mattress. The Protekt Aire 4000DX/5000DX operating manual indicates that mattress settings should be adjusted according to the user’s weight or a health care professional’s suggestion. Resident 3’s most recent recorded weight was 178 lbs, but observations on multiple occasions showed the air mattress set at 240 lbs and later at 270 lbs. There was no physician order in the electronic health record for the air mattress or its settings. The DON confirmed that setting the mattress for a much higher weight would increase pressure for a lighter resident, and the Director of Compliance confirmed that air mattresses should be set according to the resident’s weight or practitioner-ordered settings.

For Resident 1, who was cognitively intact, required assistance with mobility and ADLs, was always incontinent of bladder, frequently incontinent of bowel, at risk for pressure ulcers, and had a Braden score of 13, the comprehensive care plan identified risk for impaired skin integrity due to incontinence, decreased mobility, Braden risk, prior MASD, and excoriation to the buttocks. The care plan included interventions such as repositioning, nutrition and hydration support, keeping skin clean and dry, weekly monitoring and documentation of skin injuries with measurements, and use of pressure reduction mattress and wheelchair cushion. On 04-22-2025, an unstageable pressure ulcer to the right heel was documented, with treatment orders and a protective boot, and the care plan was updated to include heel protectors and treatment as ordered. Subsequent progress notes in December documented a stage 2 pressure ulcer to the right heel with serial measurements and a large fluid-filled blister on the top of the right foot, which later opened and increased in size. A weekly skin evaluation on 12-04-2025 noted a diabetic foot ulcer and buttock redness, but there was no weekly skin evaluation documented on or around 12-11-2025, resulting in an 11‑day gap between 12-04-2025 and the resident’s transfer to the hospital.

Hospital records for Resident 1 revealed additional wounds that had not been fully documented in the facility’s records. The emergency department noted a wound to the right posterior thigh with surrounding redness, foul rotting fruit odor, mild drainage, and additional skin breakdown to the right posterior heel and a large fluid-filled blister on the lateral right foot. The hospital wound ostomy care consult described three wounds: a full-thickness wound of unknown etiology on the right posterior thigh with boggy center, dark purple/maroon discoloration, slough, eschar, indurated and reddened surrounding skin, and moderate purulent, malodorous exudate; a chronic stage 2 pressure ulcer on the right posterior heel; and a stage 2 pressure ulcer on the top of the right foot. A hospital progress note identified a soft tissue infection of the pressure ulcer to the hip, and an operative note documented surgical debridement of the right posterior thigh wound with removal of necrotic skin and exposure of thigh fascia. Facility staff interviews indicated that a NA was aware of a skin issue to the right thigh near the buttocks covered with a bandage before hospital transfer, and an RN knew the resident was starting to get a pressure ulcer to the thigh but could not recall whether a treatment was in place. The DON confirmed that a weekly skin evaluation should have been completed on 12-11-2025 and that it was not, and the ADON acknowledged that causal factors for the wound on the top of the right foot had not been identified. The Director of Compliance confirmed that weekly skin evaluations were required and that the facility could not provide additional information regarding the wounds for either resident prior to survey exit.