F0686

G

Failure to Prevent and Properly Treat Pressure Ulcers in Two Residents

New Lexington, Ohio Survey Completed on 01-07-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide adequate pressure ulcer prevention and care, resulting in the development and worsening of pressure injuries in two residents. One resident was admitted with psychosis, traumatic brain injury, and schizophreniform disorder and was identified early as high risk for skin breakdown due to age and neurological conditions. Her care plan initially noted dry calloused areas on the feet and included general interventions such as incontinence checks, preventative skin care, and weekly skin inspections with physician notification of abnormal findings. A subsequent skin risk evaluation and nursing note identified her as high risk for pressure ulcer development and called for an escalated level of care to preserve skin integrity, but there was no evidence that an integrated, individualized plan of care with specific preventive interventions was implemented following this assessment.

Over the following weeks, this resident experienced multiple signs of decline that increased her risk for pressure ulcers, including a fall associated with poor balance, fluctuating and then significant weight loss, increased confusion, muscle weakness, debility, urinary tract infection, urinary retention, presumptive shingles, and edema. Despite these changes, the facility did not recognize or respond to the decline with an integrated or escalated plan of care focused on skin preservation. Documentation showed gaps in turning and repositioning, with no recorded repositioning on one full day and no day-shift repositioning on another day. Skin evaluation assessments shortly before the discovery of heel wounds documented no new skin issues, and when new heel areas were finally documented, they were described as large, discolored, non-blanchable areas with deep purple centers and surrounding discoloration, but were not staged at that time.

The resident was later documented to have two unstageable pressure ulcers on both heels and a Stage II pressure ulcer on the sacrum. Orders to offload the heels in bed, apply specific dressings, and encourage time up in a chair for wound healing were initiated only after the heel wounds were identified. The DON confirmed that prior to the skin breakdown, the resident did not have a comprehensive, integrated plan of care with preventive interventions for skin breakdown, despite her overall decline in mobility, cognition, infections, and weight loss. A regional nurse later characterized the heel areas as deep tissue injuries rather than unstageable ulcers, and the attending physician attributed the skin breakdown largely to nutrition issues, sepsis, and immobility and suggested the sacral wound might be a Kennedy ulcer, but there was no supporting documentation in the record for this.

A second resident, admitted with multiple serious conditions including an existing unstageable pressure ulcer, required extensive assistance with ADLs, was dependent for turning and repositioning, and had an indwelling catheter with frequent bowel incontinence. Physician orders specified detailed wound care for a sacrococcygeal pressure ulcer, including cleansing, application of Triad hydrophilic dressing, and later a change to alginate dressing with zinc barrier and ABD cover. Review of the treatment records for the month showed multiple dates on which the ordered wound care was not documented as completed on both day and night shifts. The DON verified there was no evidence that the sacrococcygeal wound treatments were completed as ordered on those dates. These omissions in following prescribed wound care orders for an existing pressure ulcer constituted a failure to provide the ordered pressure ulcer treatment for this resident.