F0686

G

Failure to Prevent and Properly Treat an Avoidable Unstageable Pressure Ulcer

Sedro Woolley, Washington Survey Completed on 02-23-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to implement adequate pressure ulcer (PU) prevention measures and to provide ordered wound treatment for a resident at risk for skin breakdown. The resident was admitted with diagnoses including history of falls, muscle weakness, osteoarthritis, and scoliosis, and the hospital discharge summary documented impaired mobility and recent falls but no skin issues. On admission, the facility’s nursing assessment noted blanchable redness to the buttocks, and the admission MDS and CAA identified the resident as at risk for PU development due to limited ability to participate in incontinence care and physical dependence on staff for position changes and offloading. The care plan documented risk for skin integrity breakdown with a goal to maintain intact skin, but interventions were limited to keeping skin clean and dry after incontinence and weekly skin checks, with no individualized interventions addressing the existing buttock redness or the resident’s identified PU risk.

Over the ensuing months, Braden Scale scores consistently indicated mild risk for PU development, yet the record from admission through early January contained no documentation of education to the resident or representative regarding repositioning, mattress type, wheelchair cushion use, or other PU prevention measures. Facility policy required, at minimum, a pressure redistribution mattress, wheelchair cushion, and repositioning for residents at risk, but the resident’s medical record from mid-January through mid-February showed no physician orders for a pressure-reducing mattress or wheelchair cushion, despite an outside wound care company’s recommendation for these support surfaces. When the resident’s sacral PU was later assessed by the outside wound company, it was documented as an unstageable PU on the bilateral sacrum, and the plan included specific wound care with Santyl and foam dressings, as well as pressure-reducing support surfaces.

The facility’s implementation of ordered wound care was also deficient. A weekly skin integrity assessment on a January date documented a small opening at the top of the gluteal fold, and a provider note the same day described a small, deep, painful open area with surrounding blanchable redness. Subsequent wound care orders directed cleansing with normal saline, application of skin prep and Santyl, and coverage with foam dressing every evening shift every three days. However, when surveyors observed the resident in late February, the resident was on a standard, approximately three‑inch mattress, wearing an incontinent brief, and the sacral PU dressing was wrinkled, clumped, and dated eight days earlier, with moderate red/green/brown drainage. Although the TAR showed that an RN had documented completing dressing changes on two dates after the dressing date, the RN later stated they could not remember performing the dressing changes, reported difficulty finding supplies, and could not explain why the dressing remained dated from the earlier date. Nursing staff interviews revealed inconsistent knowledge of the PU, lack of specific documentation for repositioning, and no charting system to record monitoring of the resident’s positioning, while the ADON could not provide details on the type of mattress or wheelchair cushion used prior to PU development and stated the resident’s PU was considered unavoidable. The report states that this failure resulted in the resident developing an avoidable unstageable PU that caused pain and discomfort and placed residents at risk for skin breakdown, unmet care needs, and diminished quality of life.

Additional observations and interviews further illustrated the gaps in PU prevention and care. During the wound observation, the sacral PU measured 1.0 cm by 1.5 cm with 0.3 cm depth, with light pink wound bed and visible slough, and no odor or signs of infection. A bruise was also noted on the resident’s thigh. A CNA familiar with the resident’s care reported assisting with toileting and pericare, stated they had no knowledge of any PU, and indicated they did not reposition the resident when sleeping but did assist with repositioning when the resident was awake. Another CNA stated they repositioned the resident with pillows and that the resident did not refuse repositioning, but confirmed there was no specific charting for repositioning. A family member reported learning of the sacral PU only after hearing the resident complain of sacral pain while being assisted in the bathroom, and staff then attributed the pain to the PU. Overall, the documented and observed inactions included lack of individualized preventive interventions despite identified risk, absence of ordered pressure‑reducing support surfaces, failure to consistently perform and/or document ordered dressing changes, and lack of systematic documentation of repositioning and monitoring, culminating in the development and inadequate treatment of an avoidable unstageable PU.

The report explicitly states that the facility failed to implement measures to prevent development of an avoidable PU and failed to provide ordered treatment for the PU for this resident. It further states that the resident experienced harm when they developed an avoidable unstageable PU that caused pain and discomfort, and that this failure placed residents at risk for skin breakdown, unmet care needs, and diminished quality of life. The findings are referenced to WAC 388‑97‑1060(3)(b).