Failure to Timely Identify Developing Pressure Ulcer on Resident’s Hip
Penalty
Summary
The deficiency involves the facility’s failure to identify signs of a developing pressure ulcer in a timely manner for one resident. The resident was admitted with significant medical conditions including quadriplegia, multiple sclerosis, acute respiratory failure, and lymphocytosis. On a documented change in condition evaluation dated March 3, 2026, the Wound Treatment Nurse (WTN) recorded that a CNA reported a pressure injury on the resident’s right hip. Upon assessment, the WTN identified a stage 3 pressure injury on the right hip, measuring 3.7 x 3 x 0.3 cm, with 90% granulation tissue and 10% slough, and obtained treatment orders from the MD. The WTN stated that the resident’s right hip area had been clear with no prior skin breakdown before this finding. CNA 1 reported that staff perform daily skin checks during care and report any skin changes to charge nurses, and that residents are repositioned every two hours to prevent skin breakdown and pressure ulcers. The DON stated that staff are supposed to conduct daily skin inspections during personal care to identify and report any skin changes, and acknowledged being informed of the new stage 3 pressure injury on the resident’s right hip on March 3, 2026. Review of the facility’s “Prevention of Pressure Injuries” policy, revised April 2020, showed that staff are required to inspect the skin daily during personal care or ADLs and identify any signs of developing pressure injuries, such as non-blanchable erythema. The DON acknowledged the policy and stated she expected staff to have provided care sooner.
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