F0686

G

Failure to Provide Comprehensive Pressure Ulcer Assessment and Pressure-Relief Interventions

Austin, Minnesota Survey Completed on 03-02-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide comprehensive, ongoing assessment and individualized pressure-relief interventions for residents at risk for or with pressure ulcers, resulting in actual harm to one resident whose facility-acquired stage 2 pressure ulcer deteriorated to stage 3. For one resident with multiple sclerosis, diabetes, heart failure, neurogenic bladder and bowel, and chronic kidney disease, the Braden assessments identified moderate risk and the care plan called for heel elevation, pressure-reducing surfaces, and turning/repositioning in bed and chair. Despite repeated weekly skin assessments documenting “redness to bottom/skin breakdown” over several weeks, these assessments lacked wound location, measurements, type, or other characteristics. When a stage 2 pressure ulcer on the left buttock was first documented, there was a delay in obtaining a specific wound treatment order, and once ordered, subsequent skin assessments continued to list the wound as a stage 2 ulcer with unchanged measurements and minimal description, even after a nurse practitioner later documented that the ulcer had progressed to stage 3 with detailed measurements and wound characteristics.

From the time the stage 2 ulcer was identified until the nurse practitioner documented stage 3 status, the record did not show that existing pressure-relief interventions were evaluated for effectiveness or that new interventions were added. The resident’s repositioning schedule in bed and chair was not reassessed for appropriateness, and there was no comprehensive assessment of skin tolerance to pressure over time. Staff interviews revealed that direct care staff were unaware of the ordered frequency for repositioning in the wheelchair and relied on the resident to self-reposition, even though the resident reported sometimes being unable to feel when her buttocks were getting sore due to MS and sometimes forgetting to reposition. The resident’s ROHO cushion had been placed backwards on multiple occasions, and the resident stated that this worsened her bottom when not placed correctly. Documentation also showed that a foam dressing ordered by the nurse practitioner was omitted from the transcribed treatment orders, and treatments were carried out without the foam dressing, while weekly skin assessments continued to record the wound as a healing stage 2 ulcer with the same measurements and no detailed characteristics.

Two additional residents with buttock wounds and pressure injury risk also did not receive weekly comprehensive RN wound assessments as required by facility policy. One resident with heart failure, chronic kidney disease, pancreatic cancer, diabetes, and a history of falls had old scarring on the buttocks and was admitted with a buttock wound. Orders were in place for foam dressings and daily assessment, and a nurse practitioner later identified a stage 2 pressure injury to the left medial buttock and incontinence-associated dermatitis with multiple small open wounds. However, subsequent skin assessments lacked full wound descriptions, did not address all wounds identified by the nurse practitioner, and there was a period where no comprehensive wound assessment was documented. During observation, this resident was found lying on a completely deflated, unplugged air mattress with no other barrier between the bedframe and mattress, and staff were unsure how long the mattress had been deflated or when the resident was last repositioned. A new open wound was observed on the right buttock with macerated edges and a foam dressing stuck to the brief instead of the wound.

Another resident with heart failure, chronic respiratory failure, and chronic kidney disease had a documented stage 2 pressure ulcer on the left buttock and was assessed as moderate risk on the Braden Scale. The care plan called for turning and repositioning every two hours in bed and chair, pressure-relieving surfaces, and laying the resident down between meals to offload the buttocks. A nurse practitioner ordered a silicone bordered foam dressing and frequent repositioning/offloading, but there was no documentation of a comprehensive assessment to determine the appropriate repositioning frequency or any revision of the existing every-two-hour schedule. Serial skin assessments showed the wound measurements remaining the same for several weeks with minimal description, and when the wound later deteriorated with increased size, the assessment still lacked detailed wound characteristics. A separate weekly wound observation tool documented a stage 2 pressure ulcer with different measurements, indicating inconsistent documentation. Interviews with nursing staff and management confirmed that weekly comprehensive RN wound assessments were not being performed for residents with pressure ulcers, that staff were unclear about who was responsible for staging and comprehensive assessment, and that the DON later recognized that required RN comprehensive assessments, including full wound descriptions and evaluation of pressure-relief measures, had not been completed for these residents.

Overall, the deficiency centers on the facility’s failure to ensure that residents with or at risk for pressure ulcers received consistent, comprehensive RN wound assessments, accurate staging and measurement, timely and correctly transcribed treatment orders, and individualized reassessment of pressure-relief interventions. This failure was evidenced by incomplete and inaccurate skin assessments, lack of documented evaluation of repositioning schedules and pressure-relief devices, staff unawareness of ordered repositioning frequencies, improper use of pressure-relieving equipment such as ROHO cushions and air mattresses, and the absence of weekly comprehensive RN wound assessments despite facility policy requiring them.