F0686

D

Failure to Implement Repositioning and Off-Loading Interventions for Residents With Pressure Injuries

Evansville, Wisconsin Survey Completed on 02-25-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide pressure injury care and prevention consistent with its own policy and professional standards for two residents with existing pressure injuries. The facility’s Pressure Injury Prevention and Wound Care Management policy requires identification of risk factors, implementation of appropriate interventions, and individualized repositioning based on clinical condition, with the expectation that residents with pressure injuries receive care to promote healing and prevent additional ulcers. Despite this, staff did not follow the established care plans and interventions for the residents reviewed.

One resident, admitted with multiple sclerosis, paraplegia, and a stage 4 sacral pressure injury, had a care plan that identified limited physical mobility and risk for altered skin integrity, with an intervention to turn and reposition the resident at least every 1–2 hours. On the survey date, the resident was repeatedly observed lying on her back in bed with the head of the bed elevated about 45 degrees at multiple times from 8:00 AM through 1:14 PM, without evidence of repositioning. Certified nursing assistants later confirmed they had not provided cares or repositioned the resident during that time, and one CNA stated she did not reposition the resident until about 2:00 PM. Nursing leadership, including the ADON and DON, stated that residents with pressure injuries should be repositioned every 1–2 hours and that this resident should have been repositioned per her care plan.

Another resident, admitted with congestive heart failure, peripheral vascular disease, vascular dementia, and protein-calorie malnutrition, had a care plan identifying risk for altered skin integrity and a stage 4 pressure injury on the left great toe. Interventions included use of a foot cradle, a pressure-reducing air mattress, management of clinical conditions, and Prevlon boots to the feet while in bed, along with turning and repositioning every 2–3 hours. The wound care physician documented a stage 4 pressure wound of the left first toe with an etiology of pressure and an approach of close monitoring and off-loading. During an interview, the resident, who was cognitively intact, reported having a pressure injury on the foot and stated staff have them wear boots during the day and off at night; however, the surveyor observed the resident lying in bed with an air mattress and foot cradle in place, but the pressure-relieving boots were on the floor instead of on the resident’s feet. The DON later stated that the root cause of the pressure injury was pressure from blankets and that a foot cradle had been initiated to off-load the blankets, and confirmed the resident should be wearing the boots when in bed.