F0686

D

Failure to Implement Appropriate Pressure-Relieving Interventions for High-Risk Resident

Mattoon, Illinois Survey Completed on 02-25-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to develop and implement appropriate pressure-relieving interventions and care planning for a resident at high risk for pressure ulcers who had multiple facility-acquired wounds. The facility’s policy required initiation of preventive and treatment interventions, updating the care plan with each intervention, use of pressure-reducing surfaces based on a mattress selection algorithm, and frequent repositioning for bed- or chair-bound residents. The resident’s care plan, revised in late January, documented impaired skin integrity related to recent surgery, impaired mobility, incontinence, diabetes, and multiple pressure ulcers, including a stage 4 left ankle ulcer and an unstageable left heel ulcer. However, the care plan did not include turning/repositioning needs or frequency, despite the resident’s high Braden risk score and dependence on staff for transfers and rolling in bed.

Clinical documentation showed progressive worsening and development of multiple pressure ulcers over time. Initial skin/wound notes identified a facility-acquired unstageable left ankle pressure ulcer on 12/24, which later enlarged and was reclassified as a stage 4 pressure ulcer, and a new unstageable left heel ulcer identified in January. Additional facility-acquired unstageable/deep tissue injuries to the sacrum, left trochanter, and right shin were documented on 1/20. The wound NP’s note indicated differential diagnoses for the left ankle wound, including pressure injury, and directed continuation of pressure-relieving interventions such as a pressure-reducing mattress, routine repositioning, and offloading boots as tolerated. The resident also had significant comorbidities, including dementia, adult T-cell lymphoma/leukemia not in remission, chemotherapy-induced pancytopenia, and type 2 diabetes, and had experienced substantial recent weight loss with poor intake.

Staff interviews and record review revealed failures to implement and maintain ordered pressure-relieving devices and to use an appropriate support surface consistent with facility policy and manufacturer guidance. Pressure-relieving boots were initiated when the left ankle ulcer was first identified but were discontinued when the resident was transferred to the emergency room and were not resumed upon return, as confirmed by the DON and TAR review. The LPN and wound nurse acknowledged that the resident did not have an air/alternating pressure mattress and was on a standard pressure-relieving (flip foam) mattress, which manufacturer information indicated was appropriate only up to stage 2 pressure wounds. The wound nurse stated that air mattresses are used for stage 3 or 4 ulcers but that this was not discussed with a provider because boots were in place, and later acknowledged not realizing the limitation of the standard mattress. Staff also reported that the resident required two-person assistance for repositioning, that the standard of care was to float heels and reposition at least every two hours, and that the care plan lacked repositioning instructions and pressure-relieving interventions for the feet prior to late December.