Failure to Provide Ordered and Proper Pressure Ulcer Care for Two Residents
Summary
The deficiency involves the facility’s failure to provide necessary pressure ulcer treatment and services, consistent with professional standards of practice, for two residents with pressure ulcers. One resident, an older female with cancer, heart failure, and sepsis, was admitted without pressure ulcers but was identified on 12/09/25 as being at risk for skin alterations with an unstageable wound to the buttock. Her care plan interventions included monitoring for signs and symptoms of infection, monitoring treatment effectiveness, notifying the physician as needed, and performing weekly skin assessments. A physician order dated 12/18/25 directed staff to cleanse the coccyx with wound cleanser or normal saline, apply collagen, and cover with a dry dressing once daily. The Treatment Administration Record showed the ordered wound treatment was not completed on 12/19/25, and although LVN C documented treatment on 12/20–12/21, the Wound Care Nurse’s (WCN) initials appeared for 12/22–12/25 without the WCN recognizing or confirming those entries. Progress notes documented that on 12/18/25 a skin check identified a reopened wound to the sacrum and open areas to the left and right buttocks, with education provided on treatment and turning every two hours. On 12/22/25, a weekly skin/wound note by the WCN stated the sacral pressure injury was assessed and treated per order, with the wound cleansed and dressing changed, but no measurements or detailed wound characteristics were documented. On 12/24/25, the Wound Care Nurse Practitioner performed a first evaluation of the coccyx pressure ulcer, describing it as an unstageable pressure ulcer measuring 4.5 cm x 4.5 cm x 3.5 cm with 40% granulation, 40% slough, and 20% eschar, malodorous drainage, fragile and ecchymotic peri-wound tissue, and non-blanchable maroon discoloration. The Nurse Practitioner ordered Dakin’s solution for cleansing, iodoform packing, and a superabsorbent dressing to be changed every other day, and noted that a sharp debridement was not performed at that time. The Nurse Practitioner reported she was not notified about the wound until she arrived on 12/24/25 and that the facility had no wound culture supplies when she requested a culture. Interviews revealed multiple failures in assessment, treatment, and communication for this resident’s wound. CNA B reported first seeing the open wound on 12/18/25 and notifying LVN A, who estimated the wound to be about the size of a dime, obtained an order from the WCN, but did not personally treat or subsequently visualize the wound, assuming the WCN would do so. CNA C, who bathed the resident, noticed the wound looked more open on 12/21/25 and notified a nurse, stating that each time he saw the wound it had cream on it. LVN D, who performed wound care on 12/20–12/21, described the wound as about the size of a quarter, not very deep, and without drainage, and reported using calcium alginate and a dry dressing. The WCN stated she saw the wound on 12/22/25 and 12/24/25, described it on 12/22/25 as about the size of a tangerine and curved in but did not measure or document its size, and acknowledged she did not notify the facility physician of the wound and did not document her phone contact with the Nurse Practitioner on 12/22/25. The DON stated she never looked at the wound, and the facility physician confirmed he was only notified about the wound on 12/18/25 and was not informed of any subsequent changes or suspected infection. The resident’s responsible party reported the facility had described the area only as a “hot spot,” did not disclose the severity, and that when the resident was taken home for a holiday dinner on 12/25/25, the responsible party observed a large, dark, unstageable coccyx ulcer with necrotic tissue and a separate Stage II ulcer on the right lower buttock, then took the resident to the hospital, where the emergency department physician documented an unstageable decubitus ulcer with foul odor and necrotic tissue. The deficiency also includes improper wound care technique for a second resident with a Stage III sacral pressure ulcer and diabetes. This resident’s care plan required assessment and documentation of wound appearance, including size, depth, exudate, tissue type, odor, and location during dressing changes, and a physician order directed daily cleansing with wound cleanser, application of medical grade honey, and a bordered dressing. During an observed wound care procedure, the WCN sprayed wound cleanser on and around the ulcer, then used gauze to clean only the skin around the wound, leaving wound cleanser in the ulcer itself. After measuring the wound length, the WCN changed gloves while the DON held the resident’s left buttock away from the ulcer; when the DON briefly released the buttock, it fell onto the ulcer. The WCN then resumed care without re-cleansing the wound until prompted by a question about whether she would clean the wound, at which point she sprayed cleanser again but initially still did not remove it from the ulcer bed. Only after further questioning did the WCN use gauze to clean the wound cleanser off the ulcer and surrounding skin before applying the ordered treatment and dressing. Both the DON and the WCN later acknowledged in interviews that it was important to cleanse the ulcer and surrounding skin, and to re-clean the wound if the buttock touched it, and to remove wound cleanser from the ulcer to avoid transferring bacteria into the wound.
Removal Plan
- Assess all residents with wounds and communicate the current condition of each wound with the resident's physician and the wound care nurse practitioner to ensure proper treatments are in place to treat and heal the wounds.
- Provide education to the Director of Nursing, Treatment Nurse, and Assistant Director of Nursing on the Change in Condition policy as it relates to physician notification, following orders that promote healing and prevention of pressure ulcers, and documenting all characteristics of wounds, including measurements.
- Provide education to all nurses on the Change in Condition policy as it relates to physician notification.
- Provide education to all nurses, including the treatment nurse, on documenting all characteristics of wounds, including measurements, and following physician orders related to healing and preventing pressure ulcers.
- Complete a competency test with nurses related to physician notification, following orders that promote healing and prevention of pressure ulcers, and changes in skin.
- Designate the Treatment Nurse to complete wound care and assign coverage by the Assistant Director of Nursing, Director of Nursing, or a designated nurse when the Treatment Nurse is unavailable, with weekend wound care completed by the weekend supervisor or assigned charge nurse.
- Have the Director of Nursing and/or designee observe wounds to ensure documentation and proper notification are charted, immediately address discrepancies or concerns with the resident's physician and wound care practitioner, provide reeducation as needed, and review the wound care nurse practitioner's notes to ensure no additional concerns are noted.
- Perform an ad hoc QAPI with the Medical Director to review the IJ template, identify the root cause of the deficient practice, and discuss the facility's plan to remove the immediacy.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Failure to perform hand hygiene between glove changes during wound care. An LPN changed dressings on a resident with multiple pressure injuries, including a heavily draining, odorous buttock wound, an unstageable coccyx ulcer, and a left heel injury, but repeatedly removed dirty gloves and put on new gloves without cleaning hands in between. The LPN said she only washed her hands before starting and after finishing, while the DON stated hand hygiene was required each time gloves were changed during wound care.
A resident with multiple comorbidities and limited mobility developed a worsening right gluteal wound that progressed from an abrasion to an infected Stage 4 pressure ulcer with foul odor, purulent drainage, and sepsis requiring hospital transfer and surgical debridement. Staff documentation showed the wound deteriorated over time, but the facility could not show that the MD was properly notified of the changes or that timely action was taken. A left heel area also lacked documented treatment or prevention measures, and surveyors later observed a dark red/black area on the heel while the resident’s heels were flat on the bed.
Failure to Document and Measure Pressure Ulcer Weekly: A resident with a Stage 2 pressure ulcer, hospice status, impaired cognition, and significant care needs had a physician order for twice-weekly dressing changes and weekly wound measurements. Facility records showed multiple weeks with no wound documentation or notes that lacked wound description or measurement, despite the facility’s policy requiring weekly monitoring and detailed documentation of the ulcer, pain, mobility, treatments, and wound characteristics.
Failure to monitor and offload existing pressure injuries: A resident with encephalopathy, MI, and respiratory failure had stage 2 pressure ulcers to the tail bone and heel documented on admission, but no further wound monitoring was found. The care plan lacked repositioning and offloading interventions, and repeated observations showed the resident lying on their back with heels pressed on the bed and no pillows or other offloading devices in place. The resident said staff were not turning them or placing pillows under their feet, and the DON confirmed weekly assessments and pressure-reduction interventions were expected but did not occur.
Failure to complete and document ordered wound care for two residents with significant comorbidities and skin risk factors. One resident with ESRD, CHF, DM, and multiple foot wounds had repeated missing TAR entries and no progress note documentation for ordered dressing changes, and was later hospitalized with worsening wound infection and osteomyelitis after the wound care provider reported concern that the facility was not changing dressings as ordered. A second resident with DM and CKD had ordered sacral and heel wound care, but the record lacked skin assessment details, wound measurements, and descriptions of the wounds.
A resident with significant neurologic impairment, malnutrition, and dependence on staff developed a facility-acquired lower back pressure injury that progressed to a stage 4 wound with infection, sepsis, and surgical debridement. Surveyors observed prolonged time in the same position, a nonfunctioning air mattress, delayed meal assistance, and missing turning/repositioning documentation. Records and interviews also showed the wound worsened over time, with inadequate offloading noted in hospital documentation.
Failure to Perform Hand Hygiene During Wound Care
Penalty
Summary
The facility failed to perform hand hygiene between glove changes during pressure ulcer wound care for one resident who was cognitively intact, required substantial to maximal assistance with transfers, and had diagnoses including a thoracic vertebra fracture, muscle weakness, and right lower leg amputation. The resident was identified as being at risk for pressure ulcers and had wound orders for the left heel, right buttock, and gluteal crease. The wound assessment described a right upper buttock pressure ulcer measuring 5 cm by 6.5 cm by 2 cm with odor and heavy purulent dark brown drainage saturating the dressings, an unstageable coccyx pressure ulcer, and a deep tissue injury on the left heel with a drained blister and intact epidermal layer. During observed dressing changes, the LPN removed soiled dressings from the right buttock and gluteal fold, then removed dirty gloves and put on new gloves without performing hand hygiene. She repeated this pattern after cleaning the wounds and again while changing the left heel dressing, removing gloves and donning new gloves without hand hygiene before removing the old dressing, cleaning the heel, and applying the new dressing. The LPN stated she washed her hands before starting and after the dressing change, but did not think to perform hand hygiene when changing gloves. The DON stated nurses were to follow wound procedures during dressing changes, including hand hygiene each time gloves were changed, and that hand hygiene was done to ensure the wound does not become decontaminated when placing clean dressings.
Failure to Manage Worsening Pressure Ulcers and Document Physician Notification
Penalty
Summary
The facility failed to obtain orders and implement interventions for one resident with pressure ulcers, and the resident’s right gluteus abrasion deteriorated into an infected Stage 4 pressure ulcer. The resident was admitted with diagnoses including major depressive disorder, atrial fibrillation, obesity, osteoarthritis, and a left heel pressure ulcer. The resident was cognitively intact, required substantial to maximal assistance to roll in bed, and was dependent on staff for transfers. The care plan and MDS identified pressure ulcer risk and included interventions such as turning and repositioning every 2 hours, pressure relief devices, heel floating, weekly skin assessments, and wound specialist involvement. The right gluteus wound was first identified as an abrasion and was treated with ordered dressings, but serial skin issue reports documented progressive deterioration, increasing size, pain, drainage, odor, and slough. The wound was described as non-healing and later as unstageable, with purulent drainage and foul odor. Staff interviews showed that changes in the wound were often placed on reports or left on the physician’s desk, but the facility was unable to provide reproducible evidence that the physician was notified of the worsening wound or what response was given. The wound nurse practitioner stated she was not notified of deterioration between follow-up visits and that earlier notification could have allowed more aggressive treatment. The wound continued to worsen until the resident required bedside and then surgical debridement, IV antibiotics, and hospital transfer for shock and sepsis related to the infected pressure ulcer. Hospital records documented a Stage 4 buttock pressure wound with polymicrobial infection and sepsis due to the pressure ulcer. In addition, a left heel area noted by wound evaluation as callous-like skin with blanchable erythema and possible pressure component did not have documented treatment orders or preventive measures in the resident’s record, and later survey observation found a dark red/black closed area on the left heel while the resident’s heels were lying flat on the bed.
Failure to Document and Measure Pressure Ulcer Weekly
Penalty
Summary
The facility failed to follow physician orders and its pressure ulcer documentation policy for a resident with a Stage 2 pressure ulcer on the thoracic spine. The resident’s quarterly MDS identified moderately impaired cognition, substantial assistance needs for care, bed mobility, and transfers, hospice status with a life expectancy of 6 months or less, pain that had been severe during the assessment period, and use of scheduled and as-needed pain medication. The resident also had a pressure relieving device in the chair and on the bed. During an observation, an RN performed a dressing change, removed the old dressing, cleansed the area, and measured the wound at 0.7 cm x 0.4 cm; the RN described it as superficial with a red wound bed and well-defined edges and stated weekly wound documentation was completed in the progress notes. The physician’s telephone order directed staff to change the dressing to the thoracic spine twice weekly and measure the wound on Tuesdays until healed, while the facility’s pressure ulcer protocol required weekly monitoring and documentation of the ulcer’s location, stage, length, width, depth, surrounding tissue, wound bed, pain, mobility, current treatments, and active diagnoses. Review of the nursing progress notes showed five weeks in which the facility did not follow the order to measure weekly or document the pressure ulcer assessment per policy, including periods with no wound documentation or notes that lacked a description or measurement of the wound. Interviews with nursing staff and the DON confirmed the expectation that the wound should be assessed and measured weekly and documented in the progress notes.
Failure to Monitor and Offload Existing Pressure Injuries
Penalty
Summary
The facility failed to provide care and services to monitor actual pressure injuries and to prevent new pressure injuries for one resident who was reviewed for pressure injuries. The resident was admitted with diagnoses including encephalopathy, myocardial infarction, and respiratory failure, and was able to make needs known. During an interview, the resident stated that their sitting bones were sore. The resident was later sent to the hospital and returned to the facility. The admission nursing assessment documented a 6 cm by 10 cm stage 2 pressure ulcer to the tail bone and a 3 cm by 2 cm stage 2 pressure ulcer to the left heel, but no further monitoring of the pressure injuries was found in the EHR. A body check assessment did not list the pressure injuries, although it noted pressure ulcer prevention measures including pillow, offloading, and turning and positioning. The active plan of care showed the resident had declined a low air loss mattress, but no other interventions such as offloading and repositioning were listed. Multiple observations showed the resident lying on their back in bed with no offloading devices and heels pressed on the bed. The resident stated staff never put pillows under their feet or turned them on their side. Staff interviews confirmed that residents with pressure injuries should have positioning devices, frequent repositioning, weekly monitoring, and care plan interventions, but these were not in place for this resident.
Failure to Document and Complete Ordered Wound Care
Penalty
Summary
The facility failed to complete ordered pressure ulcer and wound care for two residents who were at risk for skin breakdown. One resident had multiple diagnoses including CKD, CHF, HTN, ESRD, muscle wasting/atrophy, anemia, and was cognitively intact with a BIMS score of 15. That resident required substantial to maximal assistance with toileting, was incontinent of urine and bowel, had two foot ulcers, a diabetic foot ulcer, and a wound infection, and was assessed as at risk for pressure ulcer development. For that resident, physician orders included daily wound care to the left calcaneus, right calcaneus, right plantar foot, and right medial foot, along with topical povidone-iodine to the right foot. The TAR for 5/2026 did not document completion of the ordered wound care on multiple dates, and the progress notes also lacked documentation that the treatments were completed on those dates. The resident’s hospital history and physical documented worsening wound infection, multiple wounds in both feet with significant purulent drainage and necrosis, and the resident reported that the nursing home should have been changing wound dressings daily but said that was not done. The wound care provider stated she was concerned the facility was not completing the dressing changes as ordered and sent the resident to the emergency room, where the resident was admitted with osteomyelitis of the right foot. The second resident had diagnoses including type 2 DM, stage 4 CKD, anemia, and HTN, and had a BIMS score of 15. The resident’s care plan identified risk for skin complications, and physician orders included daily wound care to the sacrum and right heel using wound cleanser, Medi honey, and bordered gauze. However, the nursing admission observation had no documentation that the skin was assessed, the nursing admission assessment documented skin conditions requiring monitoring/treatment without measurements, locations, or descriptions, and the skin assessment documented no new findings without documenting the current areas. There was no documentation of wound measurements or descriptions from 1/15/26 through the resident’s discharge to the hospital on 2/25/26.
Pressure Ulcer Care and Offloading Failure
Penalty
Summary
Failure to provide appropriate pressure ulcer care and prevent new ulcers from developing was identified for one resident who had multiple risk factors, including hemiplegia/hemiparesis following cerebral infarction, aphasia, vascular dementia, protein-calorie malnutrition, and dependence on staff for repositioning, transfers, dressing, hygiene, and eating. The resident’s MDS reflected she was at risk for pressure ulcers and was not on a turning/repositioning program at earlier assessment points. The resident later returned from the hospital with a stage 4 pressure ulcer and continued to have a facility-acquired wound on the lower back/spinal area that was documented as unstageable/deep tissue injury and later progressed to a stage 4 pressure ulcer with exposed bone and undermining. Record review showed the wound was first documented as a new in-house pressure ulcer on the lower back with erythema, edema, slough, and eschar, and subsequent notes described worsening size, depth, undermining, pain, and seropurulent drainage. The resident was hospitalized for sepsis secondary to an infected stage 4 lumbar pressure ulcer with deep soft tissue infection, and hospital records noted surgical debridement. Infectious disease documentation stated the lumbar decubitus ulcer was associated with likely spinous process erosion in the setting of inadequate offloading and recommended aggressive offloading and nutritional supplementation. Survey observations showed the resident remained in the same bed position for extended periods, with a wedge under the hip and the bed alarm/beeping noted, while meal assistance was delayed and the resident called out for food. On another observation, the air mattress pump was not functioning and the mattress appeared deflated, with the resident sunk into the bed. Staff interviews and record review also found missing turning/repositioning documentation, and the facility could not provide a complete investigation when requested. The resident’s care plan included turning/repositioning, pressure-reducing devices, and skin checks, but the report documented that the resident’s wound developed and worsened while these measures were not consistently evidenced in the record or during observations.
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