F0686

G

Failure to Implement Timely Pressure Ulcer Prevention for High-Risk Resident

Newton, Kansas Survey Completed on 02-25-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to identify and implement pressure ulcer prevention measures for a resident following readmission from the hospital after surgical repair of a left hip fracture. The resident had dementia with severely impaired cognition, behavioral symptoms including wandering and rejection of care, and required increasing assistance with ADLs, progressing from moderate assistance to total assistance with bed mobility, transfers, and toileting. The resident was documented as at risk for pressure ulcers on multiple MDS assessments, with contributing factors including incontinence and impaired mobility. Despite this identified risk, the resident initially had no pressure-reducing device on the bed or wheelchair and was not on a turning and repositioning program.

After the resident returned from the hospital, an admission skin and wound assessment documented no wounds to the back, bottom, feet, or heels, and a Braden Scale score of 13 indicated moderate risk for pressure injury. A subsequent dietary note also documented no open skin issues. However, the EMR lacked evidence of a significant change in condition MDS following the resident’s decline in functional status and the development of an open lesion on the foot. A CNA later reported that upon the resident’s readmission, the resident did not have an air mattress or heel booties, was not on a turn and reposition schedule, and that the CNA had informed a nurse that the resident’s heels were red. Preventive interventions such as an air mattress and heel offloading were reported as being implemented only after a wound developed on the left heel.

The resident’s left heel wound was first documented as an open blister that had opened, with a pink wound bed and dark center, and minimal drainage. A progress note described staff finding dry red streaks of blood on the fitted sheet and locating an open blister on the left heel, with a flap of skin hanging, and staff assumed the resident had rubbed the heel against the bed or sheet. Over time, the wound was measured repeatedly and treated with various dressings and topical agents, and later documented as an in-house acquired Stage 3 pressure ulcer to the left heel, present for greater than three months and staged by a wound clinic. The facility’s own policy stated that all residents are considered at potential risk for pressure ulcers and that nursing staff would evaluate skin integrity and implement preventive measures to maintain intact skin, but the resident’s care plan and staff interviews showed that preventive skin interventions were not in place until after the pressure ulcer had developed.

The EMR documented that the resident’s care plan for pressure relief, including a pressure-reducing mattress and floating both heels while in bed, was dated after the wound had already been identified. Physician’s orders for heel protection and low air loss mattress were also dated after the wound was present. The EMR lacked wound clinic notes, despite documentation that the resident was to be followed by a wound clinic. Administrative and consultant nursing staff acknowledged that they expected preventive skin interventions to be in place to avoid pressure ulcers and that the resident’s preventive interventions were not provided until after the pressure ulcer occurred. This sequence of documented risk, absence of early preventive measures, staff reports of red heels without timely intervention, and subsequent development and progression of a left heel wound to a Stage 3 pressure ulcer formed the basis of the cited deficiency.