F0686

G

Failure to Implement Timely Pressure Ulcer Prevention and Treatment Interventions

Sault Ste. Marie, Michigan Survey Completed on 02-04-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to implement timely and appropriate pressure ulcer prevention and treatment interventions for two residents, resulting in the development and worsening of pressure injuries. One resident was admitted with diagnoses including Alzheimer’s disease, adult failure to thrive, weakness, and cognitive communication deficit, and was identified on admission as having bilateral lower leg wounds, scabs/bruising on both arms, bowel incontinence, and being at risk for skin impairment. A Braden Scale score of 15 indicated risk for pressure ulcers, and the admission evaluation identified the need for a pressure redistribution mattress to the bed. Initially, a physician note documented no open wounds, but within days, moisture-associated skin damage (MASD) was identified on the bilateral buttocks, with red, eroded skin and loose stools. Nursing documentation over subsequent days repeatedly described shearing and deterioration of the buttocks, including purple areas and scattered open superficial areas, while the resident continued to have very loose stools.

Despite ongoing documentation of worsening buttock skin breakdown and the resident’s high risk factors (failure to thrive, incontinence, limited mobility), there was no timely implementation of a low air loss mattress. The facility’s own policy stated that evidence-based interventions, including moisture management and appropriate pressure-redistributing support surfaces, should be implemented for residents at risk or with existing pressure injuries. The low air loss mattress was not ordered until mid-October, after documentation that the buttocks were deteriorating, and the order required maintenance to place the mattress. Maintenance staff reported that work orders are generally completed within 48 hours and that there is no retrievable record once completed. The DON acknowledged that moisture from bowel incontinence increases pressure ulcer risk and that failure to thrive is an indication for a low air loss mattress, and confirmed that a physician order was required before placement. However, review of MARs, TARs, and POC documentation showed no order, application, or monitoring of a low air loss mattress during the period when the wounds were progressing from MASD to suspected deep tissue injury and then to unstageable pressure ulcers.

Physician progress notes documented that the resident’s buttock wounds progressed from MASD to suspected deep tissue wounds with slough/eschar, and then to unstageable pressure ulcers with nearly 100% black necrotic tissue, purulence, erythema, and induration concerning for wound infection or necrotizing fasciitis. The resident was transferred to the hospital, where an emergency department exam found a necrotizing, foul-smelling sacral and bilateral buttock wound, with imaging and labs consistent with a severe infected decubitus ulcer. The resident required urgent surgical incision and debridement, ICU admission, IV antibiotics, and had a large surgical dressing with wound VAC at discharge. Facility work order records later showed that the low air loss mattress ordered in mid-October was not documented as placed until early November, after the resident had been hospitalized and surgically treated, indicating a significant delay between identification of worsening wounds and implementation of this pressure-redistributing support surface.

The second resident was admitted with diagnoses including diabetes, adult failure to thrive, dehydration, difficulty walking, and osteoarthritis, and was documented on admission as having a right buttock rash, a left buttock blister, and pressure wounds on the right rear thigh and left gluteus. The admission nursing evaluation identified the need for a pressure redistribution mattress to the bed as an intervention. An MDS assessment showed the resident required substantial/maximal assistance with bed mobility, was dependent for transfers, had a stage 2 pressure ulcer, and was at risk for developing pressure injuries. However, review of physician orders from admission through the survey date revealed no order for a low air loss mattress, and observations on multiple occasions showed the resident in bed without a low air loss mattress, seated directly on the buttocks without a wedge or positioning device for offloading, and with heels resting directly on the mattress.

During observations, heel protection boots were seen on the nightstand rather than on the resident’s feet, and the resident reported that staff did not put the boots on because they bothered her and that a pillow was used instead. The resident also reported having an open wound on the left outer thigh. Nursing staff confirmed that the resident was fearful of turning and repositioning, had significant left knee pain, could not consistently move or reposition herself in bed, did not like to wear heel boots, and was at risk for further pressure injuries. The unit manager stated she was unaware of the resident’s refusal to wear heel protection boots but acknowledged that the resident’s admission with pressure injuries placed her at higher risk for future wounds. Across both residents, the facility did not consistently translate identified risk factors, documented skin breakdown, and care plan recommendations (such as pressure redistribution mattress and heel protection) into timely, ordered, and implemented interventions to prevent the development and worsening of pressure ulcers.

The facility’s pressure injury prevention policy defined avoidable pressure injuries as those occurring when the facility fails to evaluate clinical condition and risk factors, and to define and implement interventions consistent with resident needs, goals, and professional standards of practice. The policy specified that interventions should be based on risk and skin assessments and that evidence-based interventions, including minimizing moisture exposure and providing appropriate pressure-redistributing support surfaces, should be implemented for all residents at risk or with existing pressure injuries. In the cases of these two residents, the documented sequence of assessments, nursing notes, physician notes, and observations showed that the facility did not timely implement or consistently use pressure-redistributing mattresses, offloading devices, and moisture management strategies in accordance with the residents’ identified risks and existing wounds, leading to the cited deficiency in providing appropriate pressure ulcer care and preventing new ulcers from developing.