Failure to Implement and Update Pressure Ulcer Prevention and Treatment Led to Avoidable Unstageable Coccygeal Ulcer
Summary
The deficiency involves the facility’s failure to adequately assess, monitor, and implement individualized pressure ulcer prevention and treatment interventions for multiple high‑risk residents, resulting in an avoidable, unstageable coccygeal pressure ulcer for one resident that required surgical debridement and hospitalization. The resident had primary progressive multiple sclerosis, hereditary spastic paraplegia, obesity, and pre‑existing pressure‑related deep tissue injury to the left heel, and was identified as high risk for pressure ulcers on the Braden Scale due to constant moisture, chairfast status, very limited mobility, inadequate nutrition, and friction/shear risk. Hospital records on readmission documented irritant contact dermatitis of the bilateral gluteal cleft with specific cleansing and barrier cream orders, and facility documentation showed the resident could not reposition in bed or chair and required assist of two and a full‑body mechanical lift for transfers. Despite this, the admission/readmission skin assessment and weekly skin checks lacked measurements and detailed wound characteristics for the heel ulcer and gluteal dermatitis, and the care plan did not include comprehensive, individualized interventions beyond generic repositioning and wound care orders. After a new coccyx pressure ulcer was identified and documented as a stage 2 lesion, the facility failed to promptly and accurately update the care plan and implement recommended pressure‑relieving interventions. The wound nurse practitioner on 3/5 ordered coccyx wound care, an air mattress, pressure offloading, and a dietician consult, but the care plan was not revised and there was no evidence that an air mattress was placed on the bed for nearly two weeks. The environmental services director later confirmed that when the resident was moved to a new room, the gel mattress was not transferred, and the air mattress requested on 3/17 was not actually placed until the following day, despite being marked as completed. During this period, TAR documentation showed gaps in the every‑2‑hour repositioning order, and staff interviews revealed that CNAs were unaware of which residents were on repositioning programs, were not consistently repositioning residents, and had not received recent education on pressure ulcer prevention. The DON and RN case manager acknowledged that the coccyx wound increased in size and changed color between assessments, that the bed lacked the ordered gel mattress, and that the physician was not notified of the wound’s deterioration at that time. The facility also failed to timely modify toileting and incontinence care practices despite knowledge that the resident was being left on a bedpan for extended periods. The DON reported hearing before an IDT meeting that the resident had fallen asleep on a bedpan for an undetermined amount of time, but the care plan was not revised to discontinue bedpan use and implement a bedside commode until after the coccyx wound had significantly worsened. CNAs confirmed that the resident sometimes fell asleep on the bedpan and that they were not informed she should no longer use it until after the sore had worsened. Subsequent wound assessments documented rapid progression of the coccyx wound from a small stage 2 ulcer to a large, malodorous, necrotic wound with eschar, slough, erythema, and purulent drainage, ultimately classified as an unstageable pressure ulcer. The DON, NP, PA, and medical director all indicated that the lack of a pressure‑relieving mattress, failure to adjust pressure‑reducing interventions, and prolonged time on a bedpan likely contributed to the development and deterioration of the resident’s pressure ulcer, which was determined to be avoidable and resulted in hospitalization and surgical debridement. Additional documentation and interviews showed systemic assessment and communication failures related to pressure ulcer management. Weekly skin checks and wound assessments often omitted complete measurements, staging, and wound characteristics, and changes in wound size and appearance were not consistently recognized as deterioration or communicated to providers. The DON acknowledged that a 3/12 assessment showing increased wound size and purple discoloration should have been identified as a deep tissue injury and reported to the physician, but this did not occur. When nursing later documented foul odor, increased pain, and expanding necrotic tissue, telemedicine and PA responses deferred in‑person evaluation and ED transfer despite earlier recommendations that the resident be sent to the ED if an in‑person provider could not assess the wound. The NP ultimately found a large, malodorous, purulent wound with expanding eschar and ordered transfer to the hospital, where imaging and surgical findings confirmed a large necrotic sacral wound requiring extensive debridement. Throughout this sequence, the facility did not consistently follow its own pressure ulcer protocols, did not ensure ordered pressure‑relieving equipment was in place, and did not promptly revise care plans or interventions in response to known risk factors and documented wound changes. The report also notes that other residents reviewed for pressure ulcers were affected by similar failures in monitoring and individualized intervention, though detailed narratives focus primarily on this resident. Staff interviews revealed that CNAs relied on paper care guides that did not clearly identify residents on repositioning programs or at risk for skin breakdown, and that they were unaware of some residents’ special mattress orders or toileting restrictions. The DON and medical director stated that residents at risk for pressure ulcers should have immediate pressure‑relieving interventions and that existing ulcers require ongoing evaluation to prevent deterioration, but the documented practices for this resident did not align with those expectations. These combined actions and inactions—insufficient assessment detail, delayed or missing care plan revisions, failure to implement ordered support surfaces and repositioning, and delayed response to wound deterioration—constituted the deficiency in providing appropriate pressure ulcer care and preventing new ulcers from developing.
Penalty
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Failure to provide proper pressure injury care for two residents. One resident with a coccyx pressure injury had an ordered daily dressing change missed, and the MAR lacked a clear reason for the omission. Another resident had a documented heel pressure injury, but the record lacked measurements, staging, wound description, preventive measures, and treatment. The DON confirmed the ordered care was not followed, and an RN confirmed the second resident did not receive proper pressure injury treatment.
A resident with a TLSO brace and limited mobility developed a worsening buttock pressure ulcer that was not fully assessed, not promptly communicated for treatment changes, and not consistently covered by timely antibiotic therapy while infection and pain were documented. The wound later deteriorated with tunneling, necrotic tissue, and a new coccyx pressure ulcer that progressed to Stage IV with osteomyelitis after hospital transfer. A second resident had pressure-related skin breakdown with delayed wound assessments and treatment orders, no added individualized care plan interventions, and a CNA provided care without gown and gloves despite EBP being in place.
Failure to Provide Ordered Heel Offloading and Pressure Injury Care: Multiple residents with diabetes, CKD, hemiplegia, COPD, and existing pressure injuries were found without ordered heel offloading devices or proper repositioning. Physician orders for bunny boots or Heelz Up support were not reflected in the aides’ Kardex/point-of-care instructions, and staff observed residents lying low in bed with heels against the footboard or mattress, with one resident reporting heel pain and another stating he had been asking for help for hours.
Failure to provide ordered wound vac treatment for a resident with a stage IV sacral pressure ulcer. The resident’s CRNP ordered NPWT at 125 mmHg with dressing changes twice weekly, but the device had problems, was removed, and the TAR showed changes only once weekly instead of as ordered. The wound care nurse and DON confirmed the ordered treatment was not provided as directed.
A resident with DM, a stage 4 sacral PI, and diabetic foot ulcers did not receive documented daily skin checks despite being at high risk for skin breakdown. The care plan called for skin observation every shift, but the DON confirmed there were no Daily Body Check records for several days, and the WCNP stated the resident’s condition required daily assessment to detect early skin impairment.
A resident with a stage 2 coccyx wound and severe cognitive impairment did not receive ordered wound care as the Wound Care Nurse applied triad paste without first cleaning the wound bed. The resident was incontinent of urine and bowel, and the DON and Wound Care Doctor both stated the wound should have been cleaned before treatment was applied.
Failure to Provide Proper Pressure Injury Care
Penalty
Summary
The facility failed to ensure proper treatment of pressure injuries for two residents. One resident was admitted with malnutrition, cancer, and chronic pain, and had an impaired skin integrity care plan for a coccyx pressure injury with goals that the ulcer would not increase in size and would not show signs of infection. Physician orders directed daily cleansing with normal saline, application of Santyl, calcium alginate, and a dry dressing. During a dressing change observation, the old coccyx dressing was found dated 8/3/26, and the LPN confirmed that the dressing change ordered for 8/4/26 had not been completed. The MAR also showed the dressing was not changed on 8/4/26 and was marked as other, with no explanation documented for why the ordered treatment was not provided. A second resident was admitted with pneumonitis, stroke, and hemiplegia, and the admission observation documented a pressure injury/ulcer on the left heel. However, the clinical record did not include measurements, stage, wound description, preventive measures, or treatment for the heel pressure injury. The facility policy required pressure injuries to be assessed initially and at least weekly, with documentation of location, stage, size, drainage, pain, wound bed, surrounding tissue, infection, and treatment orders. An RN confirmed the facility failed to make certain the resident received proper treatment for the pressure injury.
Failure to monitor and treat worsening pressure ulcers
Penalty
Summary
The facility failed to ensure timely antibiotic therapy and wound monitoring for a resident with a worsening left buttock pressure ulcer, and the resident later developed a coccyx pressure ulcer with infection and severe pain. The resident had a recent vertebral fracture, wore a TLSO brace, and had dementia, hypertension, anxiety, depression, and spinal stenosis. The record shows an abrasion to the left buttock was identified, but no Risk Management Assessment or Skin-Other Assessment was completed for that wound, and the assistant director of nursing confirmed the facility was not completing the expected skin assessments. The same resident later developed a right heel wound, and the care plan was not updated with individualized interventions after the wounds were identified. The left buttock wound worsened and was debrided, with odor, moderate purulent drainage, and signs of infection documented. A wound culture was obtained, and an antibiotic order for ciprofloxacin was entered with a scheduled start date, but the medication administration record did not show antibiotic therapy for several days while the wound continued to show infection. The wound culture results were received, but the nurse practitioner stated the results were not reviewed until later, when a different antibiotic was prescribed. The medical director stated staff should have notified the physician when the antibiotic course ended and the wound still showed signs of infection and increased pain. The resident reported significant pain during wound care, and staff notified the ADON. The wound continued to deteriorate, with later documentation of tunneling, necrotic tissue, and a new coccyx pressure ulcer that progressed to Stage IV with osteomyelitis after hospital transfer. The resident’s power of attorney stated the resident was unable to reposition independently and believed repositioning was not consistently completed because it caused pain. The ADON stated the facility could not locate documentation of spinal precautions or movement limitations related to the TLSO brace, and staff acknowledged the resident could only be repositioned slightly with pillow support. The resident was ultimately transferred to the hospital for wound tunneling and possible infection, and the hospital record documented IV antibiotics, wound debridement, and a diagnosis of osteomyelitis associated with a Stage IV sacral pressure ulcer. For the second resident, the record showed pressure-related skin problems on admission and after hospitalization, but wound measurements, wound assessments, and physician notification were not documented until later. Treatment orders for the coccyx and left buttock wounds were not entered until several days after the wounds were identified, and the care plan did not include additional individualized interventions after the wounds were found. The resident was also placed on Enhanced Barrier Precautions, but during observation a CNA entered the room and provided care without gown or gloves, and later confirmed PPE should have been worn and that the resident was on EBP.
Failure to Provide Ordered Heel Offloading and Pressure Injury Care
Penalty
Summary
The facility failed to make certain residents were provided necessary treatments and services, consistent with professional standards of practice, to treat and/or prevent pressure ulcers for four residents. The report states that the facility policy required prevention of avoidable pressure injuries and treatment to heal pressure ulcers, prevent infection, and prevent additional pressure injuries. Review of records, observations, and staff interviews showed that ordered heel offloading and protective devices were not consistently included in care instructions available to nursing assistants, and residents were observed without the ordered pressure-relief measures in place. Resident R1 had diabetes and dementia and was assessed as very high risk for pressure ulcers. Although the care plan directed staff to administer treatments and follow prevention protocols, it did not include information on bunny boots. A physician ordered offloading boots to both heels while in bed every shift, but the TAR listed this as an informational order for licensed nurses, and the Kardex for nurse aides did not include the instruction until later. A practitioner noted open wound/breakdown with blanching discoloration of the heels and recommended side-to-side offloading and heel offloading per protocol. Later, the wound nurse documented that the resident had been complaining of heel discomfort, was not wearing bunny boots, had a boggy right heel, and had a deep tissue injury on the left heel. Resident R2 had diabetes, chronic kidney disease, and an unstageable pressure ulcer, and was at moderate risk for pressure ulcers. The care plan required turning and repositioning at least every two hours, and the physician ordered bunny boots to both heels at all times while in bed and turning/repositioning every two hours. The Kardex did not include instruction for staff to assist with bunny boots. During observation, the resident was found lying low in bed with heels directly atop the wooden footboard and stated that his heels hurt. He said he had been asking since 9:30 for help, and a later observation showed he was still positioned on his back. Resident R3 had diabetes and hemiplegia following a stroke, was totally dependent on staff to roll left and right in bed, and had multiple pressure injuries including a Stage 3, a Stage 4, and three deep tissue pressure injuries. The care plan directed staff to elevate heels and assist with turning and repositioning, and the physician ordered heels floated while in bed with bunny boots on at all times. The Kardex included heel elevation but not bunny boots. During observation, the resident was lying low in bed with the left foot pressed directly against the footboard, only the right foot had a bunny boot, and staff walked past without assisting him to relieve pressure on the foot. A later observation showed him still positioned on his back. Resident R4 had COPD, muscle wasting, and a leg fracture. Progress notes documented deep tissue injuries to both heels, then a Stage 2 pressure injury on the left heel and a deep tissue injury on the right heel. The physician ordered bilateral heel offloading on a Heelz Up pillow while in bed, but the Kardex did not include instruction for staff to assist with use of the Heelz Up pillow or a regular pillow. During observation, the resident’s heels were directly on the mattress without a Heelz Up pillow or other pillow in use, no additional pillow was available in the room, and staff walked past without assisting to relieve pressure on the foot. A later observation showed the heels still were not elevated.
Failure to Provide Ordered Wound Vac Treatment
Penalty
Summary
The facility failed to provide proper treatment for a stage IV sacral pressure ulcer for one resident. The resident had diagnoses including cancer, depression, and a stage IV sacral pressure ulcer, and the care plan directed staff to administer treatments as ordered and monitor effectiveness. A wound care consult on 6/8/26 documented that the Certified Nurse Practitioner ordered wound vac therapy at continuous pressure of 125 mmHg with dressing changes twice a week, and the resident’s wound vac had been ordered but was still pending arrival at that time. A follow-up wound care consult on 6/11/26 documented that the wound vac had arrived and was applied, but nursing had difficulty with the device because it produced an error code and beeped throughout the night. Nursing removed the wound vac and used saline-moistened gauze with a dry dressing daily afterward. The physician order entered on 6/12/26 directed wound vac therapy dressings three times a week and as needed, with attachment at 125 mmHg every Monday, but the June 2026 Treatment Administration Record showed the wound vac was changed only on 6/15/26 and 6/22/26. The wound care nurse confirmed the consultant had ordered changes twice a week, but the resident’s wound vac was changed only once a week, and the ADON and DON confirmed the facility failed to provide the wound care treatment as ordered.
Failure to Complete Daily Skin Checks for a High-Risk Resident
Penalty
Summary
The facility failed to assess and complete daily skin checks for one resident who was at high risk for pressure injuries. The resident had a history that included type 2 diabetes mellitus, a stage 4 sacral pressure injury, and a diabetic foot ulcer. The Minimum Data Set showed severely impaired cognitive skills for daily decision making, substantial to total assistance needs for multiple activities of daily living, and that the resident was at risk for pressure injuries with unhealed pressure injury and diabetic foot ulcers. During record review and interviews, the treatment nurse confirmed the resident’s care plan called for observing the skin for redness, circulatory problems, and skin checks every shift. The wound care nurse practitioner stated the resident’s daily skin check should have been done because the resident had diabetes, poor circulation, limited mobility, and poor nutrition, and that non-blanchable heel redness would not develop overnight. The DON reviewed the Daily Body Check Report worksheets and confirmed there were no records for the resident from 2/11/2026 through 2/16/2026, stating that if there were no records, no assessment or skin checks were done. The DON also stated the facility policy required daily skin observation during routine care and weekly skin checks by the licensed nurse, and that the policy was not followed.
Failure to Clean Coccyx Wound Before Applying Treatment
Penalty
Summary
The facility failed to ensure that a resident with a stage 2 coccyx wound received necessary treatment and services consistent with professional standards of practice to promote healing and prevent infection. The resident had multiple diagnoses including overactive bladder, muscle wasting and atrophy, contractures of multiple sites, osteoarthritis, heart failure, and cerebral infarction. The annual MDS reflected a BIMS score of 4, indicating severely impaired cognition, and the resident was always incontinent of urine and bowel. The care plan included treatment for the coccyx wound, and the physician ordered cleansing the coccyx with normal saline, patting it dry, and applying triad paste daily. During wound care observation, the Wound Care Nurse and Wound Care Doctor entered the resident's room, positioned the resident on his right side, and opened the brief. The wound area on the coccyx was described as a small open area that was pale pink in color. The Wound Care Nurse applied triad paste to the coccyx area without cleaning the wound bed first. In interview, the Wound Care Nurse stated she should have cleaned the wound before applying the paste and said not doing so placed the resident at risk for infection. The DON and Wound Care Doctor both stated the wound should have been cleaned before treatment was applied.
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