F0686

D

Failure to Provide Comprehensive Pressure Injury Prevention, Assessment, and Treatment

Milwaukee, Wisconsin Survey Completed on 01-06-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide pressure injury prevention and treatment consistent with professional standards of practice for one hospice resident with multiple comorbidities, including primary progressive MS, chronic kidney disease, osteoporosis, severe protein-calorie malnutrition, and cirrhosis. The resident was always incontinent of bowel and bladder and had a prior history of a stage 3 coccyx pressure injury that had healed earlier in the year. The care plan identified the resident as at risk for pressure ulcers and included general interventions such as encouraging peri hygiene with barrier cream after incontinence, observing skin for redness and breakdown, use of a low air loss mattress, heel floating, use of a pressure-relieving cushion, turning and repositioning during rounding, and use of a lift sheet. However, the care plan did not specify person-centered details such as the frequency of turning and repositioning or how often the resident should be checked and changed for incontinence, despite documentation that the resident was always incontinent.

A new facility-acquired pressure injury to the sacrum/coccyx was identified on 12/11/25, documented as a full-thickness wound measuring 1.0 x 0.5 cm. The skin assessment summary did not include a comprehensive assessment: depth was not documented, wound bed color was marked as inapplicable, and the stage was entered as “Further assessment required.” Treatment ordered at that time was to cleanse with normal saline and apply zinc covered with a foam dressing, and a hospice nurse note indicated a new order for cleansing with normal saline, barrier cream to non-open areas, and Mepilex dressing. The December TAR showed the Mepilex treatment every three days was signed as completed through the end of the month. There was no comprehensive hospice documentation of the wound, and the resident’s care plan was not revised to reflect the new pressure injury or to add new, individualized interventions. An RN later stated that when new wounds are found, staff “just measure it” and “don’t stage wounds,” and there was no documentation of wound characteristics such as appearance or exudate at the time of discovery.

On 12/18/25, the wound physician assessed the sacral wound and documented it as an unstageable full-thickness pressure injury due to necrosis, measuring 7 cm x 10 cm with moderate serous exudate and 20% thick adherent devitalized necrotic tissue. The physician ordered a dressing regimen including daily calcium alginate and collagen powder with a gauze island border dressing. The facility did not correctly transcribe these orders to the TAR: collagen powder was omitted, and both the original Mepilex every-three-days treatment and the new daily alginate regimen were signed out as completed concurrently. Staff did not clarify with the wound physician which treatment should be discontinued. An LPN later reported she had only been performing the three-times-weekly border dressing, had not been using the calcium alginate because the resident complained it burned, and had not contacted the wound physician; there was no documentation that any physician was notified that the ordered treatment was not being followed. Weekly comprehensive wound assessments and measurements were not consistently completed by an RN in the absence of the wound physician; the next documented assessment with measurements after 12/18/25 did not occur until 12/29/25, was entered by an LPN, and repeated the physician’s prior measurements and description. The DON acknowledged that nurses were only verbally told to assess wounds when the wound doctor would not be present and that there was no formal assignment or sign-out process for these weekly assessments.