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