F0686

G

Failure to Perform Timely Skin Assessments and Implement Pressure Ulcer Prevention

Columbus, Ohio Survey Completed on 01-15-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to accurately assess skin integrity, follow hospital recommendations, and implement timely, specific interventions to prevent pressure ulcers or promote healing of existing skin damage. One resident was admitted with hospital documentation of a skin tear and discoloration on the buttocks and coccyx, along with explicit preventive recommendations such as turning every two hours, use of a low air loss mattress with limited linens, and avoiding briefs. On admission, the facility’s nursing assessment documented no skin conditions, and no treatment orders were obtained for the documented buttock and coccyx issues. The initial care plan identified risk for impaired skin integrity but contained no specific interventions for several days. Subsequent skin checks repeatedly documented moisture-associated skin damage (MASD) to the buttocks without consistent measurements, and additional areas on the thighs were later noted as present on admission without prior documentation or treatment orders. The resident continued to receive routine incontinence care, and adult briefs were used despite the hospital’s recommendation to avoid them.

Over the following weeks, the facility did not conduct thorough or consistent skin assessments, and newly identified areas were not promptly measured or treated. Weekly skin assessments were ordered, but documentation showed incomplete follow-up and lack of detailed wound measurements for multiple days. On one date, the wound nurse identified three new in-house acquired pressure ulcers on the rear thigh, coccyx, and left buttock, which had not been previously staged. These wounds were later staged as unstageable pressure ulcers by the wound nurse practitioner. Interviews with the wound nurse practitioner, DON, corporate nurse, and unit manager confirmed that nursing staff did not identify the wounds in a timely manner and that thorough skin assessments were not completed, despite prior hospital documentation of skin issues and the resident’s dependence on staff for toileting and mobility.

Another resident, cognitively intact but dependent on staff for toileting and frequently incontinent, was readmitted from the hospital with no documented skin issues. Within days, skin checks identified new MASD to the buttocks and coccyx, and treatment orders were initiated. However, subsequent skin assessments documented ongoing MASD without measurements, and shower/bath documentation indicated no open areas. Later, the MASD progressed to an in-house acquired stage III pressure injury to the coccyx. A wound nurse practitioner later confirmed the presence of a stage III pressure ulcer and stated that MASD can worsen to stage III if turning and repositioning are not consistent, and that with two-hour checks and changes the wound could have been identified at stage II. The DON reported that during specific weeks, LPNs were staging pressure ulcers even though they should not have been doing so, and there had been a period without a wound practitioner or physician in the facility, leaving monitoring of wound progression to facility nurses.

A third resident, with severe cognitive impairment and high dependence for mobility and toileting, had documented risk for pressure ulcers and a physician order to encourage use of Prevalon offloading boots each shift. The care plan also directed staff to float the resident’s heels while in bed. Observations on multiple occasions showed the resident in bed without offloading boots and without heels floated. CNAs and an LPN confirmed the resident did not have offloading boots and had reddened areas on both heels. The wound nurse practitioner later observed blanchable redness on the left heel. These findings occurred despite facility policy requiring comprehensive admission skin evaluations, implementation of appropriate preventive measures, ongoing monitoring, weekly evaluation and staging of pressure injuries, and CNA reporting of new skin impairments, as well as NPUAP guidelines emphasizing thorough head-to-toe skin assessments, focus on bony prominences, and use of each repositioning as an opportunity for brief skin inspection.

The combined findings show that three residents at risk for pressure ulcers, all dependent on staff for toileting and/or mobility, experienced failures in timely and thorough skin assessment, incomplete or delayed documentation and measurement of skin impairments, lack of adherence to hospital recommendations and internal policies, and inconsistent implementation of preventive interventions such as offloading devices and regular repositioning. These failures resulted in in-house acquired unstageable pressure ulcers for one resident and a stage III pressure ulcer for another, and placed the third resident at risk with unaddressed heel redness.