F0686

G

Failure to Provide Standard Pressure Ulcer Prevention, Treatment, and Skin Assessments

Allendale, Michigan Survey Completed on 03-26-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide pressure injury prevention and management in accordance with professional standards and facility policy for three residents, including failure to assess, care plan, treat, and communicate about pressure injuries and skin integrity. For one resident with a history of craniotomy, debility, incontinence, and malnutrition risk, the facility did not accurately identify or document a sacral/buttock pressure injury on readmission, did not notify the resident’s spouse or provider of a newly identified stage 1 pressure area, and did not update the care plan to include bowel incontinence or specific pressure-relief interventions. Subsequent skin assessments and physician notes did not reference a buttock wound, despite a Braden score indicating high risk and documentation that the resident was dependent on staff for repositioning. When an open area to the buttock was later identified and an alternating pressure mattress ordered, there was no documented notification to the spouse or provider and no immediate treatment order; the first documented wound treatment was initiated approximately 24 hours after the wound was identified.

As the wound progressed, the facility did not consistently update the care plan or notify the resident’s spouse of changes in wound status, debridement procedures, or treatment changes. A wound consultant documented progression from a stage 2 to stage 3 and then to a stage 4 sacral pressure injury with increasing size and depth, requiring mechanical and sharp debridements and changes in topical therapy (Triad, Medihoney, then Dakin’s solution). The EMR lacked documentation of family notification for these changes, and the care plan was not revised to reflect the worsening wound, new diagnosis of pneumonia, or additional interventions to promote healing. Laboratory results showed declining albumin and protein levels and elevated WBCs, but there was no documentation of new interventions in response to these abnormal labs at the time they were reviewed. The wound treatment with Dakin’s solution was implemented more frequently than ordered for a period, without documentation of clarification with the wound provider. The resident later reported that ordered q2h turning was not being done, and hospital records described a large stage IV sacral ulcer with exposed bone and presumed osteomyelitis; the death certificate listed a stage 4 sacral ulcer due to malnutrition, with malnutrition related to dysphagia and a benign meningioma.

For a second resident with existing pressure injuries and osteomyelitis, the facility did not follow the wound clinic’s order for a silicone bordered dressing to the right buttock three times weekly. Instead, concurrent and conflicting treatment orders were in place: zinc cream after each incontinence episode, a three-times-weekly dressing change, and an additional daily border gauze dressing ordered by the facility provider after a nurse erroneously believed there was no existing order. These overlapping orders resulted in wound care being performed more frequently than ordered by the wound clinic, and the EMR contained no documentation explaining the rationale for the additional treatment order. For a third resident with Parkinson’s disease, protein-calorie malnutrition, muscle weakness, and documented risk for impaired skin integrity, the facility failed to complete weekly skin assessments as ordered and as outlined in the care plan. Skin assessments were missed or delayed by 10 to 18 days, and there was no documentation in the EMR explaining the missed or late assessments. The Regional Nurse Consultant confirmed that weekly skin assessments were required by policy and that CNA shower sheets were not to replace licensed nurse skin assessments, yet these assessments were not completed as directed.