F0686

D

Failure to Prevent and Manage Pressure Ulcers and Document Skin Monitoring

Chicago, Illinois Survey Completed on 02-26-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide appropriate pressure ulcer care, prevent new ulcers, and adequately document skin monitoring for multiple residents, resulting in new unstageable pressure ulcers. One resident (R1) had multiple comorbidities including diabetes, anemia, hypertension, hyperlipidemia, schizoaffective disorder, bilateral hearing loss, and impaired mobility. R1 initially had incontinence-associated dermatitis (IAD) to the left buttock documented on 12/9/25, with treatment ordered but no mention of an air mattress intervention on the skin alteration evaluation. By 12/16/25, R1 had developed a new unstageable pressure ulcer from the sacrum to buttock, documented by the wound NP and in subsequent wound assessments as largely covered with slough. The care plan for risk of pressure ulcer development, including the need for assistance with repositioning and transfers and the use of pressure-reducing devices, was not updated until 12/31/25, approximately 24 days after the sacral pressure ulcer was first documented. There were discrepancies between the MDS documentation and wound assessment dates regarding when the wound was first observed, and the air mattress was not ordered until 12/16, one week after identification of a skin impairment.

R1’s skin monitoring documentation was incomplete and lacked detail. The Shower/Bathing & Skin Monitoring records between 12/1/25 and 12/17/25 showed multiple entries marked “yes” for bathing but did not describe skin condition, and the facility was unable to provide documentation of skin integrity observation details when requested by surveyors. On 12/16/25, records showed that R1 received a shower or bath, but there was no documentation by CNAs, nurses, or the wound care nurse of alterations in skin integrity that day, despite the presence of a new unstageable sacral pressure ulcer documented in wound care records. Staff interviews indicated that CNAs reported performing daily skin assessments and documenting skin impairments in the electronic record, but the surveyors verified that the follow-up question report for skin assessment and showers did not document R1’s skin integrity. The DON and Wound Care Coordinator acknowledged that air mattresses are used for residents with wounds or at risk for skin breakdown and that refusals of care should be care planned, but there was no documentation of refusal related to pressure-relieving surfaces for R1.

A second resident (R3) was admitted with an intact deep tissue injury (DTI) to the sacrum and intact skin to the mid-back, with a Braden score of 8 indicating high risk for skin breakdown and intact cognition. Early wound assessments documented a sacral DTI present on admission and a new mid-back DTI with intact epithelium and evidence of deeper tissue injury. By 01/06/26, wound assessments showed that both the sacral and mid-back wounds had progressed to unstageable pressure injuries with malodorous odor post-cleansing, increased size, and 100% slough at the mid-back site. Progress notes identified R3 as high risk for pressure sore development and ordered a low air loss mattress and offloading/repositioning interventions; however, the Wound Care Coordinator stated that although she believed there was a standing order for air mattresses and claimed R3 refused an air mattress, she had no documentation of such refusal and did not place an order. The wound care nurse similarly stated that R3 refused the low air loss mattress but admitted she did not document the refusal. Review of progress notes and care plans showed only one entry of R3 refusing wound care and no documentation of refusal of an air mattress or other care, despite staff statements that refusals should be documented and care planned.

The facility also failed to consistently implement and document infection prevention measures related to worsening wounds. R3’s wounds later cultured MRSA and E. coli, and staff interviews indicated that the wounds showed signs of infection and had an odor. The Infection Preventionist stated that residents with wounds should be placed on Enhanced Barrier Precautions (EBP), which are to be care planned, and that she was never informed that R3’s wounds were worsening or showing signs of infection. She indicated that, had she been informed, she would have contacted the Infectious Disease NP to consider empiric antibiotics. The Infectious Disease NP confirmed she had not been notified of R3’s worsening wounds after 11/19/25. Surveyors also found that the facility did not have specific policies titled “Pressure Wound Care” and “Pressure Wound Prevention,” and that existing skin care and Braden Scale policies, which required prompt identification, documentation, use of pressure redistribution mattresses, and implementation of interventions per Braden score, were not followed for R1 and R3. These combined failures in prevention, timely intervention, documentation, and communication led to the development and worsening of unstageable pressure ulcers in both residents.

The facility’s documentation systems and staff practices did not align with their written policies on skin care, Braden risk assessment, and use of pressure redistribution surfaces. For R1, there was a delay in ordering an air mattress and updating the care plan despite documented high risk and the presence of skin impairment, as well as missing or nonspecific documentation of skin assessments around the time the unstageable sacral ulcer developed. For R3, despite high risk status, admission with a DTI, and subsequent progression to unstageable wounds, there was no documented order or consistent implementation of a low air loss mattress at the time staff claimed it was offered and refused, and no documented refusals of this intervention. Additionally, staff acknowledged that they did not routinely review care plans, even though they relied on them to know resident interventions. These actions and omissions collectively constitute the deficiency in failing to provide appropriate pressure ulcer care, prevent new ulcers, and document skin monitoring as required.