F0686

G

Failure to Assess and Manage Pressure Ulcers for High-Risk Residents

Lansing, Illinois Survey Completed on 03-13-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to adequately assess, monitor, and treat pressure ulcers for two residents with significant risk factors. One resident (R3) was dependent on staff for all care and unable to turn or reposition herself, with diagnoses including hemiplegia, hemiparesis, chronic respiratory failure, obesity, muscle wasting, peripheral vascular disease, and a history of pressure-related wounds. On the day of transfer to the hospital, the CNA observed dark areas on the resident’s buttocks, and the wound care nurse identified a new dark, blister-like sacral wound and noted that the resident was not responding to questions as usual. The NP ordered transfer to the hospital for a wound evaluation due to the new wound onset but did not personally assess the wound that day. The DON and wound care nurse stated that weekend wound care staff do not measure wounds, and the wound care nurse on duty did not measure or document the size of the new sacral wound, and another nurse on shift reported never assessing the wound, relying instead on the wound care nurse.

The same resident (R3) had documented Braden scores indicating moderate to mild risk in prior months and a care plan for skin checks and reporting signs of skin breakdown, but there was no Braden score documented on the date of the new wound. The facility’s policy required that at first observation of any skin condition, the nurse describe and document it in the clinical record, notify the family and physician, and have the wound care nurse follow up with staging and measurements. Despite this, staff interviews revealed that floor and weekend wound nurses did not perform measurements, and there is no indication in the report that the new sacral wound was staged or measured before transfer. The NP explained that a wound can become infected with necrotizing fasciitis leading to sepsis and stated that the resident was sent out for a new wound onset; the report notes that this practice resulted in the resident being hospitalized for necrotizing fasciitis of the wound bed.

For another resident (R4), surveyor observation during incontinence care revealed two pink open areas with scant drainage on the left and right buttocks. The CNA providing care stated it was the first time caring for this resident and did not know if the open areas were pre-existing, while another CNA indicated that the wound care nurse should know about the wounds and that barrier cream had been ordered. The NP identified the buttock wounds as new and noted excoriation to the scrotal area, ordering hydrocolloid dressings and nystatin with barrier cream. The wound care nurse reported she had not been informed of the open buttock wounds prior to this and then applied hydrocolloid dressings and topical treatments; however, another CNA stated she had informed the wound care nurse of the open buttock areas several times weeks earlier and was told only to apply barrier cream. R4 had diagnoses including hemiplegia, hemiparesis, osteoporosis, lack of coordination, Braden scores indicating moderate to high risk, and a care plan for risk of skin breakdown and a left buttock pressure area requiring weekly systemic skin inspection, staging, and measurement. The facility’s policies required head-to-toe skin assessments on admission and regular skin assessments, as well as prompt documentation and notification of new skin alterations, but staff accounts and surveyor findings show that R4’s buttock wounds were not timely communicated, assessed, staged, or measured in accordance with those policies.