F0686

E

Failure to Prevent Pressure Ulcer After Resident Left in Chair Overnight Without Adequate Skin Monitoring

Pearland, Texas Survey Completed on 02-25-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide necessary pressure ulcer prevention and care to a cognitively impaired, bed-confined hospice respite resident who was admitted with intact skin but identified as at risk for pressure ulcer development. On admission, the resident’s assessment documented dementia, severe cognitive impairment (BIMS score 0), heart failure, low body mass index, bed confinement, and total dependence for transfers and bed mobility. The admission assessment noted intact skin and no skin issues, but the facility did not have an admission Braden skin risk assessment documented as required by policy, and no admission skin assessment was found in the record. The baseline care plan focused on respite and comfort related to hospice status and did not initially include a pressure ulcer prevention plan, and the comprehensive care plan remained closed from view until several days after admission.

On the second day of the stay, a hospice RN communicated that the resident should be placed in a chair with arms several times daily, but this order was interpreted and implemented in a way that did not ensure appropriate repositioning and monitoring. CNA A placed the resident in a comfort chair in the afternoon and reported to CNA B at shift change that the resident remained in the chair. CNA B, working the night shift, encountered the resident sleepy in the chair, attempted to interact with her, and, when the resident leaned back and did not verbalize, interpreted this as refusal to get out of the chair. CNA B left the resident in the chair throughout the night, later stating she probably left her there because the resident was comfortable and it was not a dangerous situation. CNA B did not review the resident’s medical history or admission paperwork, did not notify the nurse, ADON, DON, or oncoming aide that the resident had remained in the chair or that she observed an open sore on the resident’s bottom, and did not document any refusal or skin concern.

By the following morning, when CNA A returned, the resident was still in the chair wearing the same clothes as the previous day, and during peri care CNA A observed an open dark purple wound on the sacrum. The ADON was notified and later identified the area as a stage 2 pressure ulcer, documenting an open abrasion with a crater and dry tissue on the lower coccyx. Subsequent skin observation documented worsening with surrounding red/purple discoloration and maceration of the buttock. The facility’s own skin breakdown prevention and management policy required an initial skin and risk assessment upon admission, Braden assessments on admission and weekly for four weeks, and initiation of preventive measures and an admission care plan for residents at risk, but the Braden assessment was not completed until several days after admission and the care plan for wound prevention and treatment was not opened and updated until after the ulcer was identified. The ADON acknowledged that the order to use the comfort chair could have been misinterpreted by staff, that the care plan was not opened at admission, and that not checking on the resident did not help, while the night RN could not clearly confirm the resident’s position during night rounds. These actions and inactions resulted in the resident, who was at moderate risk for pressure ulcers, remaining in a chair for an extended period without documented repositioning or appropriate preventive interventions, leading to the development and worsening of a pressure ulcer.

The facility’s policy also required that residents at risk for pressure ulcers receive individualized care plans including pressure-relieving devices, turning and positioning, incontinence management, and protection from moisture, as well as timely investigation and documentation of any skin breakdown. In this case, the resident’s prior history of a sacral pressure ulcer during an earlier respite stay was known to the hospice RN and discussed with the ADON, but this history was not reflected in the admission assessments or used to trigger early preventive interventions such as support surfaces. The Braden assessment completed later showed a score of 13, indicating moderate risk, with very limited sensory perception, bedfast status, very limited mobility, and friction/shear risk, yet these risk factors were not systematically addressed from admission. The combination of delayed risk assessment, failure to open and implement a preventive care plan at admission, misinterpretation of the chair order, lack of effective night-time monitoring and repositioning, and failure to communicate and act on observed skin changes directly preceded the identification of a new stage 2 pressure ulcer on the resident’s sacrum.