F0686

G

Failure to Provide Comprehensive Pressure Ulcer Prevention and Treatment for Two High-Risk Residents

Twinsburg, Ohio Survey Completed on 01-05-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to implement comprehensive, resident-centered pressure ulcer prevention and treatment for two residents with significant risk factors and existing wounds. One resident was admitted with hemiplegia, contractures, diabetes, bed confinement, incontinence, and a Stage III sacral pressure ulcer, and was assessed as dependent for all ADLs and at risk for pressure ulcers. The care plan identified risk for skin breakdown and included general interventions such as administering medications and treatments as ordered and keeping skin clean and dry, but there was no documentation of specific turning or repositioning restrictions or a detailed repositioning program. Staff interviews revealed inconsistent understanding of the resident’s ability to be turned to the left or right side, and CNAs and an LPN reported that residents were not consistently checked, changed, turned, and repositioned in a timely manner, despite a facility policy requiring at least every-two-hour repositioning for residents in bed.

On one date, an RN documented discovery of a new open area on the resident’s left upper thigh/gluteal region during wound rounds, describing it as a bruise and skin tear, cleansing it with normal saline, and applying a foam dressing. However, no physician order was obtained for this new wound, and no comprehensive wound assessment or further treatment was documented until three days later. When the wound care LPN assessed the area, it was identified as an in-house acquired unstageable pressure ulcer with slough and excoriated surrounding tissue, and the wound care CNP later confirmed she was not notified of the wound until that date, despite expecting notification when new wounds occur. Subsequent documentation showed that this gluteal wound deteriorated, with increased size, 100% slough, heavy exudate, odor, dark reddish-brown surrounding tissue, and heavy dressing saturation, and the resident required oral antibiotics for a wound infection. Observation of wound care later revealed a strong foul odor, drainage on the dressing, a wound bed that was 100% dark gray with sloughing, and tunneling, with the resident moaning and yelling intermittently during care.

The same resident developed multiple additional in-house acquired unstageable pressure ulcers after admission, including to the left elbow, both heels, and right plantar foot, while staff reported that he was a “heavy wetter,” stayed in bed to help heal his wounds, and did not refuse wound care. The wound care nurse attributed the gluteal wound to the resident not getting out of bed often and being wet, and confirmed that the date recorded as the wound’s discovery on the skin issue form was incorrect, as the wound was actually found three days earlier. Observations also showed the resident lying on his backside without an indwelling catheter in place at the time, despite later orders for catheter placement, and the facility’s repositioning policy emphasized avoiding positioning on existing ulcers and maintaining a documented, monitored, and evaluated turning/repositioning program, which was not consistently implemented or documented for this resident.

For the second resident, who had multiple sclerosis, paraplegia, severe lower extremity contractures, and existing pressure ulcers, the care plan identified increased risk for skin breakdown due to impaired mobility and called for offloading heels, positioning pillows to lower extremities, and use of PRAFO boots to keep heels elevated. The MDS documented existing Stage II and Stage III pressure ulcers and use of a pressure-reducing device for the bed. During observation with a hospice RN, the resident’s severely contracted lower legs were found pressed tightly together with no device or padding to separate bone-on-bone contact. A foam dressing dated four days earlier was discovered on the left inner knee, covering a piece of calcium alginate over an open wound that measured 3 cm by 2 cm by 0.1 cm with serosanguinous drainage and red surrounding tissue.

The hospice RN stated that the area had been red the prior week and that zinc had been applied, and that the wound care nurse had been told about the area, but she acknowledged that no physician order had been obtained for zinc or for treatment of the wound. Review of the medical record with an LPN and the wound care nurse confirmed there was no assessment, documentation, or physician order for care or treatment of the left inner knee wound, including no order for zinc. The wound care nurse stated that she did not monitor wounds for residents on hospice and believed hospice was responsible, and also acknowledged that wounds were sometimes found being treated without documentation or notification. A later observation showed the resident’s contracted lower legs still lying directly one on top of the other without pillows or PRAFO boots in place, despite the care plan interventions and the facility’s repositioning policy requiring a documented, consistent repositioning program and avoidance of positioning on existing ulcers.