F0686

G

Failure to Reassess and Intervene as Pressure Ulcer Progressed to Unstageable

Toledo, Ohio Survey Completed on 02-26-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to implement and adjust interventions to prevent a pressure ulcer from worsening in a resident who was initially assessed as low risk for pressure ulcer development. The resident had multiple diagnoses including dementia, Alzheimer’s disease, autonomic neuropathy, edema, and incontinence, and was dependent on staff for most activities of daily living. The care plan in place identified the resident as at risk for pressure ulcer development due to cognitive impairment, incontinence, mobility and balance deficits, weak gait, decreased activity, and medications affecting sensory perception. Planned interventions included monitoring and documenting skin changes, notifying appropriate clinical staff of new breakdown, weekly skin assessments, use of barrier cream, dietitian assessment for nutritional needs, and management by a wound specialist center.

On a documented date, a CNA notified an RN that the resident had an open area on the coccyx, which the RN assessed as a Stage II pressure ulcer. Barrier cream was applied, and the wound care nurse was to assess the resident. The initial wound documentation described a small Stage II ulcer with scant serosanguinous drainage and epithelial tissue. A nursing plan of care was then developed to address the coccyx skin alteration, including topical treatments such as triad paste and chamosyn with honey. However, there was no evidence in the medical record of any reassessment of the resident’s overall condition or investigation into the source of the pressure ulcer at that time, and no nutritional interventions or evaluations were documented despite the resident’s identified risk for malnutrition.

Subsequent weekly wound documentation showed that the coccyx pressure ulcer progressively increased in size and changed in tissue characteristics over several weeks. The ulcer measurements increased from 1 cm by 1.5 cm by 0.1 cm to 2.0 cm by 1.5 cm by 0.1 cm, with the development of slough tissue, and eventually to 3.0 cm by 4.0 cm by 2.0 cm with foul odor and moderate necrotic tissue, at which point it was assessed as an unstageable pressure ulcer. Throughout this period of worsening, the record lacked evidence of reassessment of the resident’s condition in response to the ulcer’s progression, lacked documentation of efforts to identify the possible source of pressure, and did not show implementation of mechanical pressure relief devices, off-loading strategies, or nutritional support and evaluation. Although a wound specialist later evaluated the ulcer and made recommendations including an air pressure mattress, repositioning, frequent incontinence checks, and nutritional monitoring, the medical record did not show that these recommendations were promptly implemented, and there continued to be no documented additional interventions for mechanical off-loading or nutritional evaluation. The facility’s own skin care and pressure management policy stated that any new pressure ulcer should trigger reevaluation of the prevention plan and interventions, but the infection preventionist/wound care nurse confirmed there was no documentation that the facility attempted to determine the origin of the ulcer or implement nutritional interventions as required by the care plan and policy.

The deficiency affected one resident out of three reviewed for pressure ulcer prevention and wound healing, in a facility with a census of 89 residents. The resident’s Minimum Data Set assessment had identified severely impaired cognition, rejection of care on some days, dependence on staff for ADLs, always incontinent of bowel and bladder, and an in-house acquired unstageable pressure ulcer. Despite these identified risks and the facility’s policy requirements, the medical record showed that the facility did not reassess the resident’s condition or modify interventions in response to the development and worsening of the pressure ulcer, and did not complete nutritional assessments or implement nutritional support after the ulcer was first identified.