F0686

G

Failure to Provide Pressure Ulcer Prevention, Assessment, and Treatment for Multiple Residents

Auburn, Washington Survey Completed on 02-26-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide necessary pressure ulcer (PU) prevention and treatment services consistent with its own policy and professional standards, affecting three residents reviewed for pressure ulcers. The facility’s Pressure Injury Prevention and Management policy required Braden Scale risk assessments on admission, weekly for four weeks, quarterly, and as needed, weekly licensed nurse skin inspections, prompt reporting of open areas or dressing issues by CNAs, development of care plans with measurable goals and interventions, and provider notification of new or worsening PUs. Surveyors found that these processes were not followed: Braden assessments were not completed as required, skin and wound assessments were incomplete or missing, care plans lacked appropriate skin and wound interventions, and there was a failure to notify the provider and dietician of new wounds.

For one resident with bilateral humerus fractures, moderate cognitive impairment, and total dependence on staff for all ADLs, the admission MDS and admission collection tool documented no PUs on entry, only surgical wounds and bruising. A Braden assessment shortly after admission identified this resident as at moderate risk for PUs, but no further Braden assessments were documented and no skin or wound care plan or preventive interventions were added to the comprehensive care plan. Later, skin and wound evaluations documented new open lesions on both elbows as facility-acquired, but key fields such as the exact date of onset, wound stage, who staged the wounds, and whether the dietician was notified were left blank. Progress notes over the period when these wounds appeared contained no documentation of the new PUs, no description of staff response, and no evidence that the DON or dietician were notified. Dressing changes for the elbow wounds were not initiated and documented until several days after the wounds were first recorded, and subsequent wound evaluations were incomplete and contained wound measurements that did not match the wound provider’s assessment. The resident later reported elbow pain and stated that elbow protectors were provided only after a delay.

For a second resident who was cognitively intact, dependent on staff for several ADLs, and assessed as high risk for PUs with constant moisture, bedfast status, complete immobility, and friction/shear problems, the care plan identified a right gluteal fold shearing wound and directed staff to avoid friction and shearing, assist with repositioning, and monitor and document skin injuries. A nurse documented skin breakdown to the posterior thoracic fold and repeatedly charted on this back wound over several months, describing it at one point as open and fleshy, but the notes did not indicate that the provider was informed, what type of wound it was, or any wound measurements. No skin/wound evaluations were completed for this back wound. Later, hospital transfer orders listed four wounds present on admission, including a right gluteal fold PU and additional full and partial thickness wounds, but on readmission the RN left the skin integrity section of the assessment blank, and physician orders reflected treatment for only one of the four wounds. During observations, the resident reported pain from a right buttock wound, stated they had to ask staff for dressing changes and help with turning, and was found with no dressing over the open right gluteal fold area and wearing a brief that was too small and sitting in the wound area. A dressing on the resident’s back was dated nearly a month earlier, was soiled, emitted a strong odor when removed, and no open area was found underneath, indicating the dressing had not been changed or the area reassessed during routine care.

The DON later acknowledged that the first resident was at risk for PUs due to bilateral arm fractures, limited mobility, and potential nutritional problems, and confirmed that only one Braden assessment had been completed despite policy expectations for weekly assessments after admission and additional assessments with new skin issues. The DON also acknowledged that there was no skin/wound care plan with prevention and treatment interventions for this resident, that staff did not document progress notes or initiate an investigation or notifications when new facility-acquired PUs developed, and that skin/wound evaluations were not thoroughly completed or consistent with the wound provider’s assessments. For the second resident, the DON stated that the resident was followed by an outside wound provider and was on an air mattress with ointment and staff assistance for bed mobility, but also stated they were unsure how staff missed the long-standing dressing on the resident’s back if showers, skin checks, and care were being completed. The DON described expectations that staff notify providers of new wounds, obtain and implement treatment orders, document thorough wound assessments including measurements and pain, change dressings as ordered, and thoroughly assess skin during care, but survey findings showed these expectations were not met for the residents reviewed.