F0686

G

Failure to Provide Comprehensive Pressure Ulcer Prevention, Treatment, and Appropriate Support Surfaces

Dublin, Ohio Survey Completed on 01-26-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to implement and carry out a comprehensive, individualized pressure ulcer prevention and treatment program, resulting in actual harm to one resident and placing two additional residents at risk. One resident with multiple fractures, edema, and limited mobility was admitted with a Stage II pressure ulcer on the right upper thigh and a recent lumbar kyphoplasty incision closed with Dermabond. On admission, the baseline care plan did not identify any skin integrity concerns, despite the resident’s high assistance needs for bed mobility and a Braden score indicating risk for pressure ulcer development. A pressure ulcer care plan with specific interventions based on the Braden assessment was not developed, and the resident’s back wound was not identified until two days after admission, with no treatment order in place until another two days had passed.

When an outside wound company first evaluated the resident’s upper back on 12/10, it identified a Stage II pressure ulcer with daily treatment orders including cleansing, medical grade honey, and calcium alginate. Facility wound documentation inconsistently described the wound location (mid back, lower back) and did not add wound-specific interventions to the care plan. The Treatment Administration Record showed that the ordered daily treatment was completed on only 8 of 35 days across December and January, with no documentation of as‑needed treatments. Turning and repositioning documentation showed 11 shifts in which the resident was not turned. Braden assessments were repeatedly documented as if the resident were only at risk for developing pressure ulcers, even after the back pressure ulcer was present, and the DON later verified these assessments were incorrect and that the resident was actually at high risk. The resident did not have an air mattress in place during observation, and the wound nurse confirmed that although one had been ordered, it was not yet in use.

Over time, the resident’s back wound progressed from a Stage II pressure ulcer to an unstageable ulcer with 100% slough and then to a larger unstageable wound with odor after cleansing. The outside wound provider’s documentation and the facility wound nurse’s documentation conflicted regarding whether the back wounds were pressure ulcers or surgical wounds, whether they were present on admission, and whether the resident was on hospice or noncompliant with repositioning. The NP acknowledged miscommunication with the wound nurse and verified that the areas were on a bony prominence and not from dehiscence, while also stating there was no documentation of copious drainage or abscess despite suggesting that possibility. The facility wound nurse later verified that two separate areas on the resident’s back had been treated as one, that the care plan was not updated to address the back pressure ulcer, and that daily treatments were not completed as ordered.

The deficiency also includes failures related to pressure-relieving surfaces for two other residents. One resident with severe cognitive impairment, dependence for mobility and ADLs, and significant weight loss had an order for a pressure reduction mattress documented on the TAR, but there were no orders for an air mattress, and staff could not state how long an air mattress had been in place. Observations showed the air mattress set at 170 pounds, while staff, including the wound nurse, were unaware of the resident’s current weight or the correct setting. This resident subsequently developed an in‑house acquired Stage II pressure ulcer to the right gluteus/buttock, first identified during bathing and later confirmed by the outside wound company.

Another resident with multiple sclerosis, generalized muscle weakness, and dependence on staff for repositioning had an active order for a low air loss mattress with instructions to check function every shift, but there was no order specifying the appropriate weight dial setting and no care plan interventions to ensure correct mattress settings. Observation revealed the air mattress dial set to 325 pounds while the resident weighed approximately 173 pounds. An LPN confirmed the setting was too high and reported that the DON had instructed staff to raise the dial to make the bed firmer. The facility’s wound care policy required detailed documentation of wound care, including assessment data and resident tolerance, and required supervisor notification if wound care was refused, but the report documents missed treatments and lack of documentation of refusals or noncompliance, contributing to the identified deficiency in pressure ulcer prevention and care.