F0686

D

Failure to Implement and Follow Pressure Ulcer Prevention and Treatment Interventions

Skokie, Illinois Survey Completed on 11-21-2025

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to implement timely and appropriate pressure ulcer prevention interventions for a resident with dementia, Parkinson’s disease, significant weight loss, and documented risk for skin breakdown, and failure to consistently apply ordered pressure reduction devices after pressure injuries developed. The resident had a Braden Scale score of 15 on 10/2/25, indicating risk for pressure ulcers, with documented factors including very moist skin, very limited mobility, slightly limited sensation, adequate nutrition, and friction/shear as a potential problem. A nutrition note dated 10/15/25 documented a 17.33% significant weight loss over six months, mild anemia, risk for poor nutrition, and explicitly identified the resident as a skin breakdown risk with a goal to prevent further weight loss and skin breakdown. Despite these findings, there was no documentation of any care plan or preventive interventions implemented before the development of the right heel blister and right lateral foot stage 1 pressure injury.

On 11/10/25, during a skin check, staff identified a blister on the right heel and a skin alteration on the right lateral foot, later classified as a facility-acquired right heel blister and a stage 1 pressure ulcer on the right lateral foot. A Braden Scale completed the same day showed a score of 14, indicating moderate risk, with the resident’s activity level changed to chairfast. The resident’s MDS documented severe cognitive impairment, wheelchair use, need for supervision/touching assistance with bed mobility, partial/moderate assistance with transfers, and risk for pressure ulcers, with recommended treatments including pressure-reducing devices for chair and bed. However, the care plan dated 11/10/25 only addressed actual skin breakdown after the wounds were identified, with interventions such as protecting heels and providing new soft shoes, and there was no evidence of a prior preventive care plan or interventions despite the earlier Braden and nutrition findings.

After the wounds developed, the physician ordered offloading devices on the feet while in bed every shift for wound prevention on 11/13/25, and wound care treatments were ordered on 11/10/25. Staff interviews and observations showed that these interventions were not consistently implemented. On 11/20/25, the resident was observed in bed without heel protectors, despite CNA and nursing staff stating that heel protectors should be on at all times while the resident is in bed. The private caregiver at the bedside reported not applying the heel protectors because they were too hard to put on and acknowledged the resident’s recent mental decline, decreased mobility, and need for assistance with repositioning. The wound care coordinator and nurse practitioner both identified multiple risk factors for wound development, including dementia progression, decreased mobility, incontinence, muscle weakness, and poor or at-risk nutrition, and indicated that interventions such as heel protectors, offloading, turning, and incontinence care were needed. Additionally, the Treatment Administration Record for 11/2025 showed that ordered wound care treatments to the right heel and right lateral foot were not documented as completed on 11/19/25, and the facility’s pressure ulcer prevention policy required risk assessment on admission, weekly, and upon changes in condition, and selection of appropriate support surfaces based on risk factors, which were not fully carried out for this resident prior to and after wound development.

The facility’s own documentation further reflected gaps in assessing and documenting the unavoidability of the wounds. A Pressure Ulcer Unavoidability Screen dated 11/11/25 noted the presence of the right lateral foot pressure ulcer and right heel blister, the resident’s daily chair use, caregiver presence, and weight changes with dietitian follow-up, but did not include a score or statements explaining why the wounds were considered unavoidable. Interviews with staff indicated that the resident had a recent progression in dementia and overall decline over approximately two weeks, with decreased movement in bed and increased need for assistance with ADLs and repositioning, yet the wound care coordinator acknowledged that no heel protector order was in place before the wounds developed and that the focus had been on dietary interventions rather than additional skin and pressure prevention measures. At the time of surveyor review, there was also no evidence of updated laboratory evaluations following the resident’s decline, despite recognition that poor nutrition and anemia contributed to wound risk.

The facility’s prevention policy required review of the care plan, identification of risk factors, and implementation of interventions to reduce or eliminate modifiable risks, including appropriate support surfaces and repositioning frequency based on mobility, skin condition, and other factors. In this case, the resident’s documented risk factors—dementia, Parkinson’s disease, incontinence, chairfast status, significant weight loss, anemia, and Braden scores indicating risk and then moderate risk—were known prior to the development of the right heel blister and right lateral foot stage 1 pressure injury, but there was no documented preventive care plan or interventions in place before the wounds occurred. After the wounds developed and orders for offloading devices and wound treatments were obtained, staff did not consistently ensure that heel protectors were applied while the resident was in bed, and at least one day’s wound treatment was not documented as completed on the TAR, contributing to the cited deficiency in providing appropriate pressure ulcer care and preventing new ulcers from developing.