F0686

G

Failure to Prevent and Properly Manage Pressure Ulcers in a High-Risk Resident

Kalamazoo, Michigan Survey Completed on 02-24-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide adequate pressure ulcer prevention and care for a high‑risk resident, resulting in the development and worsening of pressure injuries. The resident was originally admitted with intact skin and diagnoses including need for assistance with personal care and muscle weakness, and was care planned as having potential for impaired skin integrity related to traumatic brain injury. Interventions on the care plan included an alternating pressure mattress, heel elevation, daily skin observation with reporting of changes, and monitoring and documentation of any skin injuries. A Braden Scale assessment showed the resident was at high risk for skin breakdown. Despite this, multiple nursing admission and re‑admission screenings documented the resident’s skin as intact or with only dry skin, and did not record sacral or coccygeal skin issues that were identified in hospital records.

Hospital documentation showed that a sacral wound was identified during a sepsis workup, with a small sacral wound draining purulent fluid and later a Grade 1 pressure ulcer to the coccyx. A subsequent hospital wound consult documented multiple pressure injuries, including an unstageable pressure injury and deep tissue pressure injuries to both heels, present on admission. When the resident returned to the facility, nursing re‑admission screenings again failed to document the coccyx/sacral wound, and early facility skin documentation on 11/11 described new in‑house gluteal abrasions without correlating them to the previously identified coccyx/sacral wound. Facility orders for wound care to the left gluteal abrasion were initiated on 11/12, and later progress notes and wound care practitioner assessments documented an unstageable coccyx pressure ulcer with slough and eschar, multiple pressure injuries to the coccyx/buttocks, heels, and elbows, and a decline of the coccyx area while in the hospital. By mid‑December, the left and right gluteal abrasions had combined into one coccyx wound, and the coccyx wound remained unstageable with a high percentage of slough and ongoing drainage.

Interviews and record review revealed systemic failures in assessment, documentation, and implementation of care. The unit manager acknowledged that the coccyx wound and elbow wounds were first identified by the facility on 11/12 and that nursing re‑admission assessments on 10/27 and 11/5 did not indicate a coccyx pressure ulcer, attributing this to missed documentation. She also confirmed missing weekly skin assessments and shower sheets, despite expectations that staff complete skin checks twice weekly during showers and weekly nursing skin assessments. Multiple LPNs reported that the resident was dependent on staff for all care, including repositioning, and that he was not receiving regular showers, skin checks, or q2h repositioning as required, often due to short staffing. One LPN stated that staff commonly skipped care and treatments, and another confirmed that residents, including this resident, frequently missed treatments and care. The January treatment administration record for coccyx wound care showed nine instances of missing documentation for ordered treatments. Family reported that the resident had no skin issues on admission, required total assistance, and was not observed being repositioned or receiving care during frequent visits, and that concerns voiced to nursing, unit management, the DON, and social work were not effectively addressed. The facility’s own pressure ulcer policy required prevention of avoidable pressure ulcers and necessary treatment and services for existing ulcers, but the documented omissions in assessment, monitoring, repositioning, and treatment led to the identified deficiency.