F0686

G

Failure to Provide Consistent Pressure Ulcer Prevention and Wound Care

Milwaukee, Wisconsin Survey Completed on 01-14-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide pressure ulcer prevention and treatment consistent with its own policies and professional standards for two residents with, or at risk for, pressure injuries. For one resident on hospice with multiple comorbidities including vascular dementia, diabetes, severe protein-calorie malnutrition, chronic kidney disease, and functional dependence, the facility did not consistently complete and document weekly skin checks as required by policy and medical orders in the weeks preceding the development of a facility-acquired stage 3 sacral pressure injury. In the eight weeks prior to the initial sacral wound, weekly skin checks were undocumented on four occasions, and when showers were refused, there was not always documentation of a completed skin assessment or of re-approach attempts, despite the DON’s expectation that skin checks still occur and be documented.

After the sacral pressure injury developed, the facility did not consistently implement and document wound treatments as ordered by the physician and wound care provider. There were delays of two days in entering and starting treatment orders for new bilateral hip stage 2 pressure injuries, and on at least one day no treatment was documented as completed for these new wounds. For the sacral wound, staff documented using Santyl when the wound provider had changed the treatment to Leptospermum (Medihoney), and there were multiple days when the sacral wound was only cleansed and covered without the ordered topical agent due to Santyl being unavailable and the new order not yet implemented. When the left hip pressure injury reopened, the wound provider’s treatment recommendations were not entered as medical orders for several days, resulting in that wound going without the ordered daily treatments from the time of reopening until new orders were entered.

Throughout the subsequent months, the facility repeatedly failed to promptly translate the wound provider’s treatment recommendations into active medical orders and to carry them out as written. Treatment changes ordered by the wound provider on several visits (including changes from Medihoney to Iodosorb, and later to Iodosorb plus calcium alginate, and then to Medihoney plus Xeroform) were implemented late, omitted, or altered by staff. For example, staff continued to use Iodosorb and calcium alginate for both the sacral and hip wounds after the provider had ordered Medihoney and Xeroform, and for a period treated the left hip with Medihoney and calcium alginate instead of Medihoney and Xeroform as ordered. During these periods of noncompliance with the wound care plan, the sacral wound increased in size and developed a high percentage of eschar, and the left hip wound increased in size.

A second resident developed avoidable, facility-acquired bilateral heel pressure injuries. Contributing factors identified in the report included failure to float the heels prior to the development of the injuries, multiple missing weekly skin checks both before and after the heel wounds were discovered, and infrequent repositioning as evidenced by staff interview and observation. An air mattress, despite being a pressure-relieving intervention referenced in facility policy, was not provided until five days after the heel pressure injuries were identified. These actions and omissions show that the facility did not consistently implement its wound prevention program requirements for weekly skin checks, pressure redistribution surfaces, and regular turning and repositioning for this resident at risk for pressure injuries.

Across both residents, the facility’s own policies required weekly skin checks documented in the EMR, prompt initiation of skin event assessments when abnormalities were noted, and implementation of individualized interventions in the care plan to prevent pressure injury development and promote healing. The report documents that these processes were not reliably followed: weekly skin checks were missed or undocumented, refusals were not consistently followed by re-approach and documentation, and wound care orders from the wound provider were not always entered accurately or in a timely manner. As a result, residents at risk for pressure injuries did not consistently receive the ordered and policy-required preventive care and wound treatments intended to prevent new pressure injuries and to promote healing of existing wounds.