F0686

D

Failure to Prevent and Timely Manage New Pressure Injuries and Related Care Planning

Chico, California Survey Completed on 03-26-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to prevent the development of pressure injuries (PIs) and to provide timely, coordinated care once PIs were identified for a resident who was admitted without any PIs. The resident was admitted with vertebral fractures and had a BIMS score of 7/15, indicating poor decision-making ability. Initial assessments documented that the resident had no pressure ulcers on admission. A licensed nurse later discovered a new stage 2 PI on the resident’s coccyx, confirming that the resident developed this PI after admission. The facility’s own policy required staff to observe for signs of potential or active pressure injury daily, but the coccyx PI was not recognized until it had progressed to stage 2, and a prior skin check did not mention any coccyx PI.

After the coccyx PI was identified, the facility did not promptly implement appropriate pressure-redistributing interventions. Although the nurse who discovered the coccyx PI stated she requested a low air loss (LAL) mattress, there was no documentation of such an order in the record, and the physician’s order for an LAL mattress was not obtained until 11 days after the coccyx PI was discovered. During this period, the resident remained on a standard medical-grade mattress, which was acknowledged as not being the mattress the resident needed. In addition, nursing staff failed to recognize the development of PIs on the resident’s heels in a timely manner. A weekly evaluation completed by a nurse did not include an actual assessment of the resident’s heels, and the nurse later acknowledged that she had missed checking them. The facility used two separate skin assessment tools that were described as time-consuming and redundant, and leadership acknowledged that this contributed to difficulty in recognizing the heel PIs.

The facility also failed to complete required assessments and care planning related to the resident’s PIs. No change in condition MDS assessment was completed for the resident after the PIs were identified, despite facility policy requiring a skin risk evaluation upon significant change in condition and the corporate resource nurse confirming that a significant change in condition MDS was not optional when PIs did not heal within 14 days. The resident’s care plan was not updated to include the stage 2 coccyx PI until eight days after its discovery and did not include the heel PIs until five days after they were discovered, even though the DON confirmed that care plans for PIs should have been developed right away after discovery. Additionally, the registered dietitian was not notified of the resident’s PIs until 10 days after the coccyx PI and seven days after the heel PIs were discovered, delaying nutritional evaluation and intervention for wound healing. The RD documented a recommendation for health shakes three times per day, but a non-dairy fortified shake appropriate for the resident’s needs was not obtained until 23 days after the coccyx PI was discovered.