F0686

J

Failure to Provide Ordered Pressure Ulcer Care and Monitoring for Two High-Risk Residents

Peoria Heights, Illinois Survey Completed on 02-13-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to identify, assess, and treat pressure ulcers, prevent a facility-acquired pressure ulcer, prevent existing ulcers from worsening, administer wound treatments as ordered, and develop and implement appropriate pressure-relieving interventions and care plans for two residents. One resident was admitted with severe cognitive impairment, was bedbound, nonverbal, and fully dependent for all ADLs, with a Braden score of 9 indicating very high risk for pressure ulcers. Despite this, the resident’s care plan did not include a problem or interventions related to pressure ulcer risk or prevention. The facility’s own policies required skin inspections, Braden risk assessments, weekly wound assessments, prompt notification of the physician and representative at the earliest sign of skin problems, and care plan revisions when skin integrity was altered, but these were not followed.

For the first resident, the skin condition report initially documented no wounds, but on a later date a wound to the coccyx was identified by a CNA and evaluated by the wound nurse, who described an open area with moderate serous drainage and scarring. A treatment order for medicated dressing and gauze twice daily was placed, but the treatment administration record showed delays in starting the treatment and multiple missed or undocumented treatments on several dates, even after the order was changed to every shift due to drainage. The wound nurse later stated the wound was getting worse, needed debridement, and that there was still no care plan for the wound, acknowledging it was her responsibility to add one when the wound was identified. Progress notes documented that the wound progressed from a stage 3 to a stage 4 ulcer with deep tunneling, purulent, odorous drainage and concerns for infection, and nursing notes described copious dark yellow drainage and worsening of the coccyx wound before the resident was sent to the hospital.

For the second resident, who was originally admitted with a stage IV coccyx pressure ulcer, tracheostomy status, gastrostomy status, critical illness myopathy, osteomyelitis, and dependence on staff for all ADLs and mobility, the care plan documented the presence of a pressure ulcer and the need for a pressure-relieving/reducing mattress and treatments as ordered. Physician orders included use of a rectal tube to protect the wound from stool contamination and specific wound care regimens, including wound vac and later wet-to-dry dressings twice daily and PRN, as well as sodium hypochlorite solution every 12 hours. Treatment administration records showed multiple missed scheduled wound treatments, no PRN wound treatments documented, and numerous missed sodium hypochlorite applications. There was no documentation of site monitoring or assessments for the rectal tube and no daily nursing skin checks in the electronic record. The rectal tube fell out and, although the physician ordered monitoring and follow-up with the surgeon, the surgeon was not notified, the rectal tube was not replaced, and there was no documentation that the gastric surgeon was contacted. The NP documented that the rectal tube had come out on two occasions, that replacement tubes were out of stock, and that the family wanted it reordered, but the tube remained unavailable. The resident’s family reported observing stool-soaked wound dressings remaining in place for over four hours before being changed. Nursing notes also documented orders for labs and imaging related to a leaking G-tube, but the electronic record contained no laboratory results for the entire admission. Staff interviews confirmed that wound care was often not completed on night shift due to workload, that missed treatments meant they were not done, that nurses were not consistently assessing skin daily, and that the DON and medical director were unaware that ordered wound treatments, skin assessments, labs, and rectal tube monitoring were not being completed.

Removal Plan

• V2/Interim Director of Nursing and V4/Assistant Director of Nursing/Wound Nurse in-serviced all licensed nurses on Physician Orders—Entering and Processing, and Documentation in the Health Record (including the Physician Orders—Entering and Processing policy).
• V2/Interim Director of Nursing and V4/Assistant Director of Nursing/Wound Nurse in-serviced all licensed nurses on Pressure Injury and Skin Condition Assessment (including the Electronic Health Record policy).
• Conducted a facility audit to identify all residents with pressure ulcers, including completing wound assessments, contacting the physician, contacting the wound nurse, reassessing the wound in 24 hours, and obtaining consents to see the wound physician.
• V2/Interim Director of Nursing and V4/Assistant Director of Nursing/Wound Nurse in-serviced staff on Pressure Injury and Skin Condition Assessment (including the Pressure Injury and Skin Condition Assessment policy) and developed a process requiring the direct care nurse to review the Treatment Administration Record prior to providing wound care.
• V2/Interim Director of Nursing and V4/Assistant Director of Nursing/Wound Nurse in-serviced staff on Pressure Ulcer Prevention and Med Error/Adverse Drug Reaction, Physician Orders—Entering and Processing, Documentation—Health Record, and Comprehensive Care Plan/Baseline Care Plan (including related policies) and implemented a process to ensure staff are trained to develop and provide interventions to prevent pressure areas and prevent pressure ulcers from worsening, including: educating staff to review the care plan before care; educating nurses on the facility skin policy; educating nurses on weekly skin assessments; educating nurses on following physician orders; educating staff on residents with pressure ulcers who are dependent on staff for repositioning; educating clinical and dietary staff to follow physician orders and meal tickets to ensure correct diet and supplements; educating nurses on following physician orders and reviewing the MAR/TAR prior to medication pass and wound care; educating nurses on conducting skin assessments upon return from hospital; educating nurses to open risk management for skin breakdown and notify the wound nurse and DON.
• V2/Interim Director of Nursing and V4/Assistant Director of Nursing/Wound Nurse in-serviced all staff on Pressure Injury and Skin Condition Assessment and Skin Condition Assessment and Monitoring—Pressure and Non-Pressure (including the Pressure Injury and Skin Condition Assessment policy).
• V2/Interim Director of Nursing and V4/Assistant Director of Nursing/Wound Nurse in-serviced all nurses and certified nursing assistants on Pressure Ulcer Prevention (including the Pressure Ulcer Prevention policy).
• V2/Interim Director of Nursing and V4/Assistant Director of Nursing/Wound Nurse in-serviced all staff on Change of Condition and Physician-Family Notification (including the Physician-Family Notification—Change in Condition policy).
• V2/Interim Director of Nursing and V4/Assistant Director of Nursing/Wound Nurse in-serviced all staff on Comprehensive Care Plan/Baseline Care Plan (including the Baseline Care Plan).
• V2/Interim Director of Nursing and V4/Assistant Director of Nursing/Wound Nurse in-serviced all staff on admission of residents (including the admission of Resident Care Plan).
• V2/Interim Director of Nursing and V4/Assistant Director of Nursing/Wound Nurse in-serviced all staff on the admission of Resident/Admission-readmission Checklist (including the admission checklist).
• V2/Interim Director of Nursing and V4/Assistant Director of Nursing/Wound Nurse in-serviced the IDT on Comprehensive Care Plan (including the Comprehensive Care Plan).
• V2/Interim Director of Nursing and V4/Assistant Director of Nursing/Wound Nurse in-serviced all staff on Infection Prevention and Control Program (including the Infection Prevention and Control Program policy).
• V14/Vice President of Operations in-serviced administration on ensuring all new admissions (referrals) equipment and supplies are obtained prior to admission.
• Held a QAPI meeting with the medical director and IDT to discuss deficiencies and facility action plans.
• Conducted a facility-wide audit for all residents’ wound care plans.
• Conducted a facility-wide audit of residents with wounds to identify any changes needed and updated the physician.
• Planned to conduct audits seven days per week for six weeks for all residents with pressure injuries.