F0686

D

Failure to Reposition Resident, Complete Skin Assessment, and Correctly Set LAL Mattress for Pressure Ulcer Management

Los Angeles, California Survey Completed on 02-18-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide pressure ulcer care consistent with professional standards and its own policies for a resident with multiple Stage 4 pressure ulcers. The resident had diagnoses including malignant melanoma of the left upper limb and shoulder, Stage 4 pressure ulcers of the left buttock and sacral region, metabolic encephalopathy, and dementia, and required total dependence for ADLs per the MDS. A wound care provider documented physician instructions for offloading and repositioning throughout 24 hours, including at night, using wedges for support and frequent incontinence garment changes to prevent moisture-associated skin damage. The resident’s care plan for risk of impaired skin integrity specified goals to prevent further skin breakdown with interventions including turning and repositioning every two hours and more frequently if needed, use of an appropriate pressure-reducing mattress, and frequent incontinence pad changes. An IDT meeting with the resident’s POA documented that the plan of care included ensuring the resident would be turned and repositioned as scheduled and as needed, side to side only, to keep pressure off the sacral open area.

Despite these documented plans and orders, the facility’s own records showed that the resident was not repositioned according to the every-two-hour schedule. Review of the ADL turn and repositioning log for nearly a one‑month period showed the resident was turned only two to three times per day, rather than every two hours as required by the care plan and IDT decisions. Interviews with the resident’s private caregiver and a CNA confirmed that the private caregiver was performing most of the resident’s ADLs, including turning, repositioning, feeding, and changing incontinent briefs, with CNAs assisting only at times. The DON acknowledged that CNAs and staff are responsible for ADL care and confirmed that the log documented turning only two to three times per day instead of every two hours. Facility policies on Prevention of Pressure Ulcers/Injuries and Activities of Daily Living required residents in bed to be repositioned at least every two hours and CNAs to turn and reposition residents at least every two hours, which was not reflected in the documentation for this resident.

The facility also failed to complete and document required skin and pressure ulcer risk assessments upon the resident’s readmission, contrary to its Admission Assessment – Nursing policy and its Pressure Ulcer/Injury Management policy. The DON and treatment nurse both stated that residents’ skin must be assessed, evaluated, and documented on admission and readmission, and that the absence of documentation meant the assessment was not done. Additionally, the facility did not ensure the low air loss (LAL) mattress was set according to the resident’s weight, as required by the physician’s order for an alternating pressure mattress and the facility’s Low Air Loss Mattress policy. The resident’s weight was documented as 158 lbs and later 156 lbs, but observation showed the LAL mattress control set to firm at 250 lbs. The treatment nurse and DON both stated that the LAL mattress setting should correspond to the resident’s weight and that an incorrect setting would not assist with wound prevention and management. These failures in repositioning, admission skin assessment, and proper LAL mattress setup constituted the deficient practices identified by the surveyors.