F0686

J

Failure to Implement and Follow Pressure Injury Orders for High-Risk Resident

Milwaukee, Wisconsin Survey Completed on 02-17-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide necessary pressure injury treatment and preventive services consistent with professional standards for a resident at high risk for skin breakdown. On admission, the resident had severe cognitive impairment, was ventilator-dependent with a trach and G-tube, was always incontinent of bladder and frequently incontinent of bowel, and was completely dependent on staff for mobility and transfers. Braden scores of 11 documented the resident as high risk for pressure injuries, yet no skin integrity or pressure injury care plan was developed on admission, despite facility policy requiring comprehensive assessment and care planning. The resident’s head of bed needed to be elevated for continuous enteral feeds, further increasing pressure injury risk, but the CNA Kardex and care plan lacked person-centered interventions for turning/repositioning or sacral off-loading, and the Kardex contained inaccurate or incomplete mobility information.

After a hospitalization, the resident returned with an unstageable sacral pressure injury and specific wound care instructions from the hospital and wound physician. The facility entered a sacral wound treatment order incorrectly as “as needed” instead of daily and failed to document treatment on at least one ordered day. On subsequent readmissions, hospital discharge summaries and wound MD notes specified updated treatments (e.g., Santyl with Vashe-moistened gauze, calcium alginate, Dakins 1/2 strength, foam-with-border dressings), but these recommendations were not consistently entered as physician orders or implemented on the Treatment Administration Record. The admission skin assessments often lacked complete wound descriptors (e.g., percentages of slough and granulation, stage), and there was no documented wound nurse admission assessment with staging after certain readmissions. The facility continued to use outdated treatment orders (such as calcium alginate or full-strength Dakins with ABD pads) instead of the wound MD’s current orders for 1/2-strength Dakins and foam-with-border dressings, even as the sacral wound progressed to Stage 4 with exposed bone and increased size and undermining.

As the sacral pressure injury deteriorated, wound MD documentation showed progression from unstageable to Stage 4 with 10% bone exposure and later 30% bone, and the resident also developed an unstageable pressure injury to the left buttock and deep tissue injuries to both heels. The skin care plan was not updated with new, person-centered interventions after the wound was staged as Stage 4, and still did not include specific turning/repositioning or sacral off-loading measures. When bone became visible, the wound MD ordered a sacral/coccygeal X-ray and, based on suboptimal imaging, a CT scan was ordered to rule out osteomyelitis. The CT scan order was marked as completed on the MAR/TAR, but there was no evidence in the EMR that an appointment was scheduled or that the CT was performed, and the receptionist responsible for scheduling outside appointments reported never receiving the CT order. The resident later required hospitalization, where imaging and consults identified sacral/coccygeal osteomyelitis with abscess and sepsis, and the resident underwent debridement and partial coccygectomy. Upon readmission after this hospitalization, the facility again mis-staged the sacral wound as unstageable and failed to update the TAR to reflect the wound MD’s orders for 1/2-strength Dakins and foam-with-border dressings, continuing instead with full-strength Dakins and ABD pads while the wound measurements increased.

Throughout this period, the facility also failed to implement a care plan for monitoring the resident while on a blood thinner (Eliquis) initiated after a hospital-diagnosed DVT. Weekly wound evaluations by the wound MD documented ongoing changes in wound size, depth, undermining, exudate, and bone exposure, and multiple hospitalizations occurred for conditions including ventilator-associated pneumonia, septic shock, and sepsis secondary to sacral osteomyelitis with abscess. Despite these changes and the documented decline of the sacral wound, the facility did not consistently follow hospital discharge wound care instructions, did not reliably enter or implement updated wound MD treatment orders, did not document complete wound assessments on readmission, and did not revise the care plan to include individualized repositioning and off-loading interventions. These failures led surveyors to determine that the resident did not receive necessary care and services to promote healing and prevent new pressure injuries, resulting in an immediate jeopardy finding.

The facility’s own policies required comprehensive admission/readmission skin assessments with descriptors, timely physician notification, appropriate treatment orders for each wound, and development and updating of person-centered care plans based on risk factors and changes in condition. However, the record showed missing or incomplete admission skin assessments, lack of staging by qualified staff at key points, failure to document or follow hospital and wound MD treatment recommendations, and absence of documented rationale for not following those recommendations. The CNA Kardex and care plan did not reflect the resident’s total dependence for mobility with clear repositioning instructions, and there was no evidence of consistent implementation of pressure-relieving interventions such as turning schedules and sacral off-loading, even as the resident’s wounds worsened and new pressure-related injuries developed.

Surveyor interviews with nursing leadership and staff confirmed that the expected process was to verify and enter hospital and MD orders on admission, complete thorough skin assessments with measurements and descriptors, and involve the wound nurse for staging and full assessment. Nonetheless, the EMR lacked documentation of these processes being carried out as described. The CT scan ordered to further evaluate suspected osteomyelitis was not scheduled despite being marked as completed, and there was no documentation in the EMR to support that the test occurred prior to the resident’s subsequent hospitalization where osteomyelitis and abscess were confirmed. Collectively, these documented omissions and missteps in assessment, care planning, order entry, and treatment implementation formed the basis of the cited deficiency for failure to provide appropriate pressure ulcer care and prevent new ulcers from developing.