F0686

G

Failure to Prevent New Pressure Injuries and Mismanagement of Therapeutic Air Mattress Settings

Little Chute, Wisconsin Survey Completed on 01-20-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide necessary care and services to prevent the development of avoidable pressure injuries and to promote healing of existing pressure injuries for two residents. One resident was admitted without any documented pressure injuries, with an admission Braden Scale score of 15 indicating high risk for pressure injury development. Admission documentation and hospital transfer orders listed only a cervical surgical incision and bruising on the hands, antecubital area, and wrists, with no sacral, thigh, or heel wounds noted. Despite the high-risk Braden score, the initial care plan created on the day of admission did not include a focus area or interventions for skin integrity, and a skin integrity care plan was not initiated until nearly two weeks later, after the resident had already been transferred to the hospital. Nursing documentation from admission through the date of hospital transfer did not include ongoing skin integrity assessments beyond the initial Braden assessment.

During this same period, staff interviews revealed gaps and inconsistencies in skin assessment and monitoring. A registered nurse reported performing a head-to-toe assessment on admission and stated that the coccyx would have been assessed only if wounds were documented on the Braden assessment, and did not recall whether a specialty mattress was used. A CNA reported that the resident had a bowel movement several days after admission and that there was a dressing on the coccyx at that time, but did not know who applied it and stated it was not removed during care. Another nurse recalled assisting with repositioning and stated that zinc was applied to the coccyx but did not recall any specific skin injuries. The DON stated that staff had documented no wounds other than the surgical incision on admission and was not aware that a dressing had been applied to the coccyx or that a skin integrity care plan focus area was only added after the resident’s hospitalization.

When the resident was admitted to the hospital, wound care documentation identified multiple pressure injuries that had not been recognized or documented by the facility. Hospital assessments described a bilateral sacral deep tissue pressure injury with serosanguineous drainage, a right posterior thigh deep tissue pressure injury, and a right heel deep tissue pressure injury, all measured and characterized in detail. An advanced practice nurse who had completed the facility admission assessment later reviewed the hospital wound photos and documentation and stated that the coccyx wound appeared older than 24 hours, while the age of the thigh and heel wounds was uncertain. The facility was unaware of these pressure injuries prior to the hospital admission, and no ongoing skin integrity monitoring or targeted interventions had been documented during the resident’s stay.

The second resident was admitted with a documented stage 4 sacral pressure injury and had a care plan and physician order for an air mattress set to 250 pounds on an alternating setting, along with a pressure redistribution cushion for the chair. The treatment administration record included an order for staff to check the function and setting of the air mattress every shift, with documentation that the mattress was set appropriately at 250 pounds. However, surveyor observations on two consecutive days showed that the air mattress was actually set at 350 pounds, first on an alternating mode and then on a static (non-alternating) mode, contrary to the care plan and orders. The most recent recorded weight for this resident was 156 pounds, and manufacturer guidance indicated that the mattress setting should be as close as possible to the resident’s current weight to ensure proper pressure relief.

Despite these requirements, staff documentation in the TAR indicated that the air mattress was correctly set at 250 pounds on the shifts when surveyors observed it at 350 pounds and, on one day, in static mode. An LPN stated that staff were responsible for checking the air mattress setting each shift and documenting it, and that incorrect settings should be corrected and reported to the DON or wound nurse. The DON later confirmed that the mattress had been set too high and that it was not on the alternating mode as ordered. The discrepancy between the observed settings and the documented TAR entries, combined with the failure to match the mattress setting to the resident’s actual weight and prescribed alternating mode, demonstrates that the resident with a stage 4 sacral pressure injury did not receive care and services consistent with the care plan, physician orders, and manufacturer guidelines for pressure redistribution therapy.