F0686

G

Failure to Timely Assess, Treat, and Prevent Worsening Pressure Ulcers

Sioux Falls, South Dakota Survey Completed on 02-04-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide appropriate pressure ulcer care and prevention for a resident admitted with an existing stage II coccyx pressure ulcer and multiple areas of skin redness. On admission from the hospital, transfer orders specified detailed skin breakdown risk interventions, including Q2H repositioning, heel elevation, moisture protection, use of a lift pad, and specialty bed if indicated. The admission skin assessment documented a stage II coccyx ulcer with specific measurements and no redness to ankles, elbows, or hips, and the Braden Scale indicated high risk for pressure ulcer development. However, although a physician’s order for heel boots while in bed was dated the day of admission, it was not set to start until several days later, and an air mattress was not ordered until weeks after admission. The facility’s own policy required a baseline skin assessment on admission, immediate prevention plans when potential areas were identified, and a wound assessment when a pressure injury was identified, but the wound nurse did not complete an initial wound assessment until eight days after admission.

In the days following admission, there were significant gaps in monitoring, documentation, and implementation of wound care and preventive interventions. A family member reported that a nurse was unaware the resident had bed sores, that the wound nurse was on vacation, and that dressings placed on the buttocks remained unchanged for nearly two weeks. On 1/6, an LPN, prompted by the family, assessed the resident and found Mepilex dressings on the hips, right ankle, and coccyx, with an open area on the coccyx and redness on the right outer ankle and elbows; the removed dressings were dated from the admission date. At that time, there were no wound treatment orders in the EMR, no scheduled skin evaluation, and no air mattress, wheelchair cushion, or Prevalon boots in use, despite the resident’s high risk and existing wound. Another LPN completed a skin assessment on 1/7 after the family again raised concerns, noting an open coccyx area with slough and red areas on hips, ankles, and elbows, but did not measure the wound, relying instead on the wound nurse’s future weekly rounds. The order for Mepilex dressing changes every three days did not begin until eight days after admission.

When the wound nurse finally documented the coccyx wound on 1/8, it was staged as a stage III pressure ulcer with slough and maceration of surrounding tissue, and subsequent documentation showed inconsistent and incomplete assessment of additional pressure areas, including the right outer ankle, which was later identified as a pressure ulcer without measurements or full description. Physician orders for Arginaid to support wound healing were not attempted to be administered until several days after the order date, and a documented daily Santyl dressing order was not recorded as completed on at least one scheduled day. Observations in early February showed the resident thin and frail, with an air mattress in place and Prevalon boots sometimes off, heels resting on the mattress or recliner footrest, and periods in a recliner without a seat cushion. Interviews with nursing leadership confirmed that the wound nurse did not evaluate or provide preventive interventions or treatments for the resident’s wounds between admission and 1/8, that the care plan was not updated with wound-related interventions at admission, that there was no skin assessment or evaluation policy beyond the general pressure injury prevention program, and that delays in pressure reduction interventions and treatment could have delayed healing of the coccyx pressure ulcer.