F0686

G

Failure to Accurately Assess and Implement Pressure Ulcer Prevention and Treatment

Wells, Minnesota Survey Completed on 02-05-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to adequately assess, monitor, and implement individualized pressure ulcer prevention and treatment for two residents at risk for pressure injuries, resulting in actual harm to one resident. One resident with chronic kidney failure, heart failure, atrial fibrillation, obesity, decreased mobility, incontinence, and oxygen use was identified on admission as at risk for pressure ulcers, with dry skin on both heels and a foam dressing on the coccyx. The Braden assessment showed risk but did not include clinical suggestions to reduce pressure ulcer development, and the baseline care plan did not include pressure reduction interventions. The admission MDS identified the resident as dependent for bed mobility and transfers and at risk for pressure ulcers, but the resident was not placed on a turning and repositioning program, had no nutrition or hydration interventions, and had no dressing or treatments to the feet. There was no comprehensive assessment of tissue tolerance to pressure over time to support the chosen repositioning schedule.

Several days after admission, staff documented a pressure area on the right heel with redness and a blue area, applied skin prep, a foam dressing, and puffy boots, and notified the provider, but the note lacked detailed wound characteristics. An incident report identified an unstageable pressure ulcer on the right heel, and a skin integrity care plan was initiated two days later, listing multiple interventions such as heel protection boots, pressure-relieving mattress and cushions, and turning and repositioning every two hours. However, the record between admission and this care plan did not show a comprehensive assessment to determine appropriate repositioning frequency. Subsequent wound assessments of the right heel and sacral/coccyx area were repeatedly inaccurate: a dark purple heel wound was documented as a stage 1 pressure injury instead of a deep tissue injury, and an open sacral wound was documented as an open lesion or stage 2 coccyx ulcer instead of an unstageable or stage 3 sacral pressure ulcer as later confirmed by the DON and a wound clinic. The wound clinic documented a stage 3 sacral pressure ulcer requiring debridement and recommended frequent turning and repositioning, but there was no indication that the facility reassessed the repositioning schedule after this visit.

Observations showed that ordered interventions were not consistently implemented. The resident was seen in a wheelchair with the right heel resting directly on the metal foot pedal without Prevalon boots, despite care plan directions for heel protection when foot pedals were in use, and the resident reported heel soreness. The sacral area was observed without the ordered dressing on more than one occasion. The pressure-redistributing wheelchair cushion was found slipping forward so that most of the resident’s buttocks were on the bare wheelchair seat, and the NA acknowledged the cushion needed an antiskid pad. Treatment records showed missed applications of ordered skin protectant to the heel and wound dressings to the coccyx/sacrum on multiple days. The consulting RD reported not being informed of the resident’s pressure ulcers and therefore made no nutrition recommendations. A second resident, with hemiplegia, heart failure, atrial fibrillation, and high Braden risk (constantly moist, chairfast, completely immobile, very poor nutrition), was readmitted from the hospital with heels noted as a little red and with instructions that heels had been floated. The facility revised the care plan to include turning, repositioning, and heel protectors, but again there was no comprehensive assessment of tissue tolerance to justify the every-two-hour schedule.

For this second resident, a new right heel open area was documented, but the skin assessment lacked detailed wound characteristics and there was no corresponding physician order at that time. A subsequent skin issue assessment described a blister that had reabsorbed fluid, but again lacked detailed descriptors. Hospice documentation identified a right heel blister with peeled skin and a non-adherent dressing, with instructions to ensure heels were floated and to use a foam dressing, but the facility’s physician orders for heel treatment were delayed and changed over several days. Later wound assessments described a blister with light drainage and foam dressing, while corresponding images showed an open blister extending from the lateral to the back of the heel with shiny, macerated skin and irregular edges. The DON acknowledged that the wound appeared worsened and that the assessment was inaccurate. During observation, the resident was in bed with heel protectors, but the right heel was resting directly on the air mattress rather than being fully floated. A hospice RN removed the dressing and identified two stage 2 pressure ulcers on the right heel (lateral and back), and stated these were caused by incorrect repositioning and failure to keep the heel floated. The facility’s own pressure injury prevention and management policy required a systematic approach with prompt assessment, intervention, monitoring, and modification of interventions, which was not followed in these cases.