F0686

G

Failure to Prevent and Manage Pressure Ulcers and Implement Ordered Offloading Interventions

Worthington, Ohio Survey Completed on 02-09-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to prevent the development and worsening of pressure ulcers and to implement and maintain ordered interventions for multiple residents at risk for skin breakdown. One resident was admitted without pressure ulcers but was dependent for bed mobility, had severe cognitive impairment, and was frequently incontinent. The care plan identified risk for impaired skin integrity but did not include specific interventions for staff assistance with turning and repositioning in bed. The Braden Scale was not consistently re-evaluated when a new pressure injury developed, and there was no unavoidable pressure ulcer assessment. An in-house unstageable right heel pressure ulcer later documented as a stage III ulcer developed, and the resident subsequently developed an in-house unstageable coccyx pressure ulcer that had previously been documented only as MASD without measurements or detailed assessment. Throughout this period, there were no documented refusals of turning and repositioning, yet staff interviews confirmed the resident remained on her back much of the day and required assistance to turn.

The same resident’s care plan and physician orders lacked clear, complete interventions and parameters for pressure-relieving equipment. Orders for an air pressure mattress did not include settings, and staff had not been educated on how to operate different types of air mattresses. Observations showed the air mattress set for a much higher weight than the resident’s actual weight, and the resident was observed in bed without offloading boots and with heels not elevated, despite orders for bilateral offloading boots and heel elevation. MASD to the coccyx and buttocks was documented in progress notes without measurements, detailed descriptions, or treatment orders, and there was no documented assessment by a physician, NP, or RN of the MASD area. The wound care process relied heavily on an LPN to assess, stage, and measure pressure injuries and MASD in the absence of the consulting wound NP, with no verification of accuracy by an RN, NP, or physician, and MASD areas were not routinely measured or fully described.

A second resident with chronic conditions, including diabetes and venous insufficiency, required substantial assistance with bed mobility and was always incontinent. This resident developed a facility-acquired right heel deep tissue injury that was initially documented without measurements or description. After hospitalization and readmission, the resident had a right heel open area and bilateral buttocks MASD, but again the second skin sweep documented an unstageable heel ulcer and MASD without measurements or detailed descriptions. MASD was later described only as improving in progress notes, still without measurements. Following another hospitalization and readmission, the resident no longer had the heel injury or MASD, but there was no active order for offloading boots despite a history of a facility-acquired heel injury and a prior care plan intervention for offloading boots. Observations confirmed the resident remained on his back in bed without offloading boots, and he reported needing help to turn and only being turned when he asked.

A third resident was admitted with severe protein-calorie malnutrition, right-sided hemiplegia, total dependence for bed mobility, and a hospital-documented stage IV sacral pressure ulcer. The admission assessment documented a coccyx pressure ulcer, and the care plan identified actual impaired skin integrity and risk for pressure injury but did not include interventions for staff assistance with turning and repositioning, despite the resident’s inability to reposition independently. Physician orders included an air pressure mattress and bilateral offloading boots, but the care plan did not add offloading boots as an intervention, and no mattress settings were specified. Subsequent skin assessments showed the sacral stage IV ulcer had deteriorated in size. Observations revealed the resident in bed without offloading boots, with the air mattress initially not on the bed and later placed on the bed at maximum firmness without physician notification or staff knowledge of appropriate settings. Staff interviews confirmed the resident was totally dependent on repositioning, that documentation of turning and refusals was inconsistent, and that staff had not been educated on the various air mattresses used.

Across these residents, the facility’s own skin management policy required comprehensive admission/readmission skin evaluations with location, measurements, and characteristics documented, implementation of appropriate preventive measures for at-risk residents, documentation of interventions on the care plan, and completion of Braden Scales with significant changes. The findings showed repeated failures to measure and describe pressure areas and MASD at discovery and during follow-up, to update Braden Scales when new pressure injuries occurred, to include and implement specific turning/repositioning and heel offloading interventions in care plans, and to ensure ordered pressure-relieving devices (air mattresses and offloading boots) were correctly set up, used, and monitored. Staff interviews confirmed that CNAs did not always document turning or refusals, that care plans and Kardexes did not clearly indicate turning schedules, and that nurses did not consistently verify repositioning or have clear orders for turning frequency, contributing to the identified deficiencies in pressure ulcer prevention and care.