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
Resources
Below are regulatory guidelines relevant to this citation:
Failure to Reposition Resident With Stage 4 Pressure Ulcer: A resident with diabetes, CAD, HTN, and a stage 4 coccyx pressure ulcer was assessed as needing repositioning every 2 hours, but during prolonged observation staff did not offer repositioning while the resident remained in the same position in bed. The care plan called for turning and repositioning per tissue tolerance, but the bedside Kardex did not specify how often to reposition. When the issue was identified, RN and the ADON turned the resident and noted blanchable redness on the left buttocks and upper thigh.
Failure to provide ordered wound care for a resident with an unstageable pressure injury. The resident had chronic venous insufficiency and cellulitis, and the MDS showed the resident was cognitively intact with a pressure ulcer present on admission. A physician ordered xeroform gauze, Dakin's-soaked Kerlix packing, and an ABD pad twice daily, but observations found the wound without the ordered dressing and packing, then later with a soiled dressing and protruding packing. An LPN confirmed the dressing was soiled and undated/untimed, and the ADON acknowledged the findings.
Pressure ulcer prevention and wound care failures were identified for multiple residents. A resident with immobility and diabetes developed a facility-acquired sacral wound that progressed to an infected stage 4 ulcer requiring hospitalization and debridement, while surveyors observed missed wound vac documentation, stool-contaminated dressings, improper offloading, low air loss mattresses on static mode or incorrect weight settings, missing heel protectors, and a wheelchair resident without a pressure-relieving cushion.
Failure to Clean and Monitor a Pressure Injury: The facility failed to promote healing of a resident’s unstageable DTI to the right ischium. During wound care, the DON applied treatment without cleaning the wound first, despite staff and the wound physician stating that cleansing with saline or wound cleanser was appropriate. The record also lacked weekly nursing assessments documenting the wound’s location, stage, size, and description, and the facility relied on intermittent wound physician visits that were missed when the resident was at dialysis or out of the facility.
Failure to Measure and Offload a Right Heel Pressure Injury: A resident with DM, PVD, and a history of skin breakdown developed a right heel PI that was identified as a deep tissue injury and later progressed to stage 2 and then unstageable. Staff did not obtain wound measurements for about two weeks after discovery, several skin reviews lacked wound details, and surveyors observed the resident without ordered offloading boots in the recliner and wheelchair even though staff said the boots were to be worn at all times.
Failure to Prevent and Treat Pressure Ulcers: A resident with impaired cognition, total ADL dependence, incontinence, and high Braden risk developed worsening sacral and heel pressure injuries after staff did not consistently implement wound prevention measures or recognize the change in condition when sacral redness was first noted. The wound progressed to an infected stage IV sacral ulcer with foul odor, drainage, altered mental status, and hospital transfer; interviews and records also showed the wound was not consistently tracked or care planned, and the resident’s skin breakdown was not promptly escalated.
Failure to Reposition Resident With Stage 4 Pressure Ulcer
Penalty
Summary
Provide appropriate pressure ulcer care and prevent new ulcers from developing was not met for a resident with diabetes mellitus, coronary artery disease, hypertension, and a stage 4 coccyx pressure ulcer. The resident’s MDS identified dependence for lower-body dressing, transfers, toileting, and substantial to maximal assistance with rolling in bed. The care area assessment noted chronic pressure ulcers and diabetic foot ulcers, that the resident was often noncompliant with repositioning, and that he often refused to get out of bed. A tissue tolerance lying assessment identified existing wounds to the heels and coccyx and indicated the resident should be repositioned every two hours. The resident’s care plan included an air pressure mattress, nutritional supplements, and turning and repositioning per tissue tolerance, and the bedside Kardex stated the resident needed two staff for turns and boosts with a lift sheet, but it did not include how often to reposition him. During continuous observation from 7:06 a.m. to 9:51 a.m., the resident remained in the same position in bed while staff entered and exited the room for breakfast, lab work, snacks, and visits. No staff member offered to reposition him during that observation period, and he remained on his back with pillows supporting his sides and lower legs throughout the observation. When the surveyor informed the clinical manager that the resident had not been repositioned as care planned, RN-A and the ADON entered the room, checked the resident’s skin, and assisted him to turn onto his right side. RN-A noted redness on the left buttocks and upper thigh that was blanchable. During interviews, NA-C stated the usual practice was to assist the resident with repositioning every 2 to 3 hours, RN-A confirmed the tissue tolerance assessment called for repositioning every two hours, and the DON stated staff needed education to check on and reposition the resident following the care plan. The facility policy on pressure ulcers/injuries described pressure injuries as resulting from prolonged pressure or pressure with shear, but it lacked interventions for care and prevention of pressure ulcers.
Failure to Provide Ordered Wound Care for Pressure Injury
Penalty
Summary
The facility failed to ensure a resident with an unstageable pressure injury received the physician-ordered wound treatment needed to promote healing. Resident 5 was admitted with chronic peripheral venous insufficiency and cellulitis of the right lower leg, and the admission MDS dated June 10, 2026, documented that the resident was cognitively intact with a BIMS score of 15 and had one unstageable pressure ulcer present on admission. A physician order dated July 3, 2026, directed staff to apply xeroform gauze to the distal aspect of the right buttock wound, pack the wound with Kerlix gauze soaked in Dakin's solution, and secure the dressing with an ABD pad twice daily and as needed for soiled or dislodged dressings. During an observation on July 8, 2026, the wound was not covered with xeroform gauze and had no wound packing in place. During a second observation on July 9, 2026, the dressing was visibly soiled with a yellow-colored substance and the wound packing was protruding from the wound; an LPN confirmed the dressing was soiled and could not determine when it had last been changed because it was not dated or timed. The ADON later reviewed and acknowledged these findings.
Pressure ulcer prevention and wound care failures
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and to prevent new ulcers from developing for multiple residents, including residents with severe cognitive impairment, immobility, ventilator dependence, diabetes, and existing pressure injuries. The report states that staff failed to implement preventive interventions to maintain skin integrity, failed to ensure low air loss mattresses were on the correct settings while in use, failed to ensure multiple linen layers were not beneath residents on low air loss mattresses, failed to timely identify skin integrity impairments, failed to follow physician orders, and failed to document or administer prescribed treatments for 10 of 33 residents reviewed for pressure ulcers. For one resident with a facility-acquired sacral pressure ulcer, the record shows the resident was dependent on staff for rolling, had a stage 3 sacral wound identified as in-house acquired, and later developed a stage 4 sacral wound with odor, heavy purulent drainage, necrotic tissue, and signs of infection. The physician documented surgical excisional debridement, noted the wound decline over one week, and recommended transfer to the emergency department. The resident was hospitalized for an infected sacral wound and later records referenced systemic inflammatory response syndrome due to the infected sacral ulcer and a plan for surgical debridement. Survey observations also found the resident lying on a low air loss mattress without the sacral wound offloaded, with a wound vac canister full of blood nearby, and staff observed the wound vac dressing was not adhered and the dressing area was covered with stool. The report also describes multiple other residents whose pressure-relief measures were not maintained as ordered. One resident’s low air loss mattress was observed on static mode and set to an incorrect weight setting; another resident’s mattress was also on static mode; and several residents were observed with heels resting directly on the mattress or with only one heel protector boot available. A resident in a wheelchair was observed without a pressure-relieving cushion despite being at risk for pressure ulcers. For another resident, wound vac treatments were not documented on two scheduled days, and staff statements showed confusion about who was responsible for wound care and when wound vac orders should be carried out. The facility policy stated that residents should receive timely, individualized risk assessments, appropriate preventive interventions, and ongoing monitoring, and that skin changes should be addressed by licensed nurses, but the observations and record review showed these measures were not consistently implemented.
Failure to Clean and Monitor a Pressure Injury
Penalty
Summary
The facility failed to provide care and services to promote healing of a pressure injury for one resident with an unstageable deep tissue injury to the right ischium. The resident was cognitively intact on the most recent MDS, with a BIMS score of 14 out of 15, and the assessment documented one unstageable deep tissue injury that was not present on admission. The resident told surveyors that staff had been applying cream to a diaper rash wound on the buttocks and said it had been there for a while. During wound care observation, the DON performed treatment to the right ischium wound but did not clean the wound before applying the dressing. The DON stated she did not clean it because the physician order did not specify cleaning with anything, and said she would have used normal saline or wound cleanser if it had been ordered. The wound physician later stated that nursing staff should use their judgment for cleaning the pressure injury and could generally use wound cleanser or house stock saline. An RN also stated that she cleansed the wound with normal saline or wound cleanser because a wound should always be cleaned before treatment. The record also failed to show weekly monitoring of the wound with the required location, staging, sizing, and description. The wound physician notes showed assessments on some dates, but several visits were rescheduled because the resident was at dialysis or out of the facility, and one refusal was documented. The clinical record did not contain additional assessments or refusals to account for weekly monitoring. Facility policy required weekly evaluation and documentation of the pressure injury by a licensed nurse and/or practitioner, including wound location, stage, measurements, tissue type, drainage, surrounding tissue, pain, and interventions to promote healing.
Failure to Measure and Offload a Right Heel Pressure Injury
Penalty
Summary
The facility failed to ensure appropriate pressure injury care and failed to prevent worsening of a resident’s right heel wound. The resident had diagnoses including type 2 diabetes mellitus with diabetic chronic kidney disease and peripheral vascular disease, and had a history of pressure injuries and skin blistering. The resident’s Braden score was 13 on 1/29/25, indicating moderate risk for pressure injury development. The care plan included interventions for skin integrity, including offloading boots to both feet when in bed and in the recliner at all times, weekly skin checks, and monitoring for skin changes. On 4/1/26, the nurse practitioner identified a wound on the right heel and documented it as a deep tissue pressure injury with surrounding dark tissue and sanguineous drainage. Orders were entered for offloading boots and wound care. However, the first wound measurements were not obtained until 4/14/26, about two weeks after the wound was discovered. The weekly skin reviews on 4/2/26 and 4/9/26 documented the wound as open, but did not include wound measurements or wound characteristics. Later wound assessments showed progression from a stage 2 wound with granulation tissue and moderate drainage to an unstageable wound with eschar covering most of the wound bed. Survey observations on 6/29/26 showed the resident in a recliner and later in a wheelchair without the ordered offloading boots in place; the boots were observed sitting in the windowsill next to the bed. Staff interviews confirmed that the boots were expected to be worn at all times, including in bed, the recliner, and the wheelchair. Staff also stated that wound measurements should be completed weekly, but acknowledged that measurements were not started until the wound was classified as a pressure injury on 4/14/26. The record also showed a missed skin assessment on 6/23/26 and several wound entries without descriptions of wound bed characteristics.
Failure to Prevent and Treat Pressure Ulcers
Penalty
Summary
The facility failed to ensure a resident with multiple risk factors for skin breakdown received necessary wound prevention and treatment services after readmission and after a later change in condition. The resident had impaired cognition, was dependent for all ADLs, used a wheelchair, was incontinent of bowel and bladder, and was identified as at risk for pressure injuries. The record also showed a Braden score indicating moderate to high risk, with documentation that the resident was bedfast, had very moist skin, and required frequent linen changes and repositioning. The resident’s records showed that weekly skin observations and care planning did not consistently reflect the development and progression of the sacral wound. A skin observation documented redness on the sacrum, and later documentation described an open area with necrotic eschar, foul odor, drainage, and worsening deterioration. The wound was later documented as an unstageable pressure ulcer to the sacrum, with bilateral heel deep tissue injuries also identified. The record review also noted that the resident was not care planned for linens being changed every shift per the Braden Scale, and the initial tracking and trending wound list did not list the resident’s wounds even though the wounds were later found to have been acquired. The resident’s condition worsened to the point that the wound became infected, cultures identified multiple organisms, and the resident was transferred to the hospital with altered mental status and a stage IV sacral decubitus ulcer with infection. Interviews reflected that staff and the wound care nurse believed the wound could have been prevented with more frequent turning and incontinence care, and the wound care nurse stated the resident should have been sent out earlier when the sacral redness was first noted. The hospital physician stated the wound was severe, had exposed bone, had a horrible odor and drainage, and appeared to have been present long before the resident was sent out.
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