F0686

D

Failure to Identify and Offload Pressure Ulcers and Implement Pressure-Relieving Devices

East Moline, Illinois Survey Completed on 02-22-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to identify and manage a pressure injury in a timely manner for a resident at risk for pressure ulcers, and failure to implement appropriate pressure-relieving interventions for two residents with pressure ulcers. One resident was admitted with multiple diagnoses including hemiplegia/hemiparesis, arthritis, chronic kidney disease, Parkinson’s disease, depression, and a history of a pressure ulcer of the left buttock. A facility assessment documented severe cognitive deficits, dependence on staff for most care, and risk for developing pressure ulcers. A Weekly Wound Evaluation dated 1/15/26 showed an in-house acquired stage 3 pressure injury to the sacrum measuring 5 cm by 1.5 cm with depth unable to be determined. The care plan identified actual impairment to skin integrity of the sacrum and risk for skin breakdown, with directions to assess for and provide appropriate pressure-relieving devices and to assess for changes in skin condition each shift.

Surveyors observed that this resident, who was bedbound, did not consistently have heel protector boots in place despite being at risk for pressure ulcers. In the morning, the resident was lying in bed with her heels directly on the air mattress while her tan inflatable heel protector boots were found under the edge of the dresser near the bed. Later that day, during wound care, the resident was observed wearing blue heel protector boots, and the wound care nurse stated there was no physician order for heel protectors but she felt the resident should wear them due to her condition and had placed them for that reason. The wound care nurse also reported that the sacral wound was first identified when a CNA reported a wound on the resident’s bottom while getting her up for the day. The treatment nurse stated it was her understanding that nurses should be documenting weekly skin checks to detect developing wounds and implement additional preventive measures, and she did not believe the resident wore heel protectors. The DON stated she would have expected early identification of wounds and the use of a low air loss mattress and heel protector boots or heel offloading for a bedbound resident.

For a second resident with an unstageable pressure injury to the coccyx/sacrum, surveyors observed that the resident was on an air mattress that was set to “firm” rather than adjusted to the resident’s weight, and the resident’s wheelchair pressure-relief cushion was flattened, torn, and leaking foam. The wound care nurse confirmed the cushion was worn and stated it was for pressure relief, and upon checking the mattress, acknowledged it was set too high and should be set to the resident’s weight. The resident appeared confused when asked about mattress firmness. Documentation for this resident showed an unstageable pressure injury with moderate serosanguinous drainage and strong odor, with the wound location changed from right buttock to sacrum due to exacerbation, and a low air loss mattress ordered. The care plan documented admission with a pressure ulcer of the right buttock related to immobility but did not include pressure ulcer preventive measures or pressure-relieving devices. The facility’s preventative skin care policy required use of Braden scores and weekly skin assessments to determine specific preventive needs, including offloading devices such as “Heels Up” or therapeutic boots for residents at high risk, and immediate reporting of any skin alterations to the charge nurse for assessment and follow-up.