Failure to Implement Ordered Pressure Ulcer Treatments and Prevention Measures
Summary
The deficiency involves the facility’s failure to provide ordered pressure ulcer treatments and to implement effective pressure injury prevention and management for multiple residents, most notably a resident with paraplegia, a suprapubic catheter, an ostomy, and a known stage IV left ischial pressure ulcer with osteomyelitis on admission. Hospital records at admission documented orthopedic surgery’s recommendation for follow-up at a tertiary center for possible debridement and plastic surgery consultation for wound coverage/closure, but there was no evidence this recommendation was carried out. On admission, the resident’s skin impairment was documented only as “pressure” without location, assessment, or measurements, and the initial wound evaluation described a left buttock stage IV ulcer with minimal detail. A wound vac treatment was ordered but not documented as completed on multiple days, and the care plan initially lacked key interventions such as turning and repositioning, heel elevation, and a low air loss mattress, despite the resident’s dependence on staff for bed mobility and transfers. Subsequent wound consultant nurse practitioner (WCNP) visits documented progressive worsening of the resident’s left ischial ulcer and the development and deterioration of additional pressure-related wounds, including a left heel unstageable ulcer, bilateral buttocks (gluteal dermatosis progressing to unstageable and then stage IV sacral involvement), and a right ischial unstageable ulcer. The WCNP repeatedly specified detailed treatment regimens (e.g., hydrogel, medical-grade honey, calcium alginate with silver, Santyl, Dakin’s solution-moistened gauze, zinc oxide, collagen, low air loss mattress, turning/repositioning, and heel floating), but the facility frequently failed to enter these orders correctly into the electronic record, omitted treatments entirely, or implemented incorrect treatments and frequencies. For example, there was no treatment order entered for the bilateral buttocks gluteal dermatosis after the 07/16/25 WCNP visit, no updated order for the left ischial ulcer at that time, and no treatment documented on the TAR for the buttocks on several days. Later, when Dakin’s solution and Santyl were ordered in the WCNP plan, the facility did not clarify the Dakin’s concentration, did not obtain Dakin’s or Santyl from the pharmacy for extended periods, and continued to provide incorrect or incomplete wound care. There was no documentation that the resident refused wound care or repositioning. As the weeks progressed, wound measurements and descriptions documented by the WCNP showed increasing size, depth, undermining, slough, eschar, exposed deeper tissues (including muscle/fascia and subcutaneous tissue), malodor, and increased exudate in the left ischial, right ischial, and bilateral buttocks/sacral areas. Despite these changes and the resident’s total dependence for bed mobility, the MDS showed the resident was not on a turning/repositioning program, and the plan of care and interventions remained nonspecific or incomplete. Laboratory monitoring revealed elevated white blood cell (WBC) counts, with a WBC of 14.9 reported and acknowledged by the facility practitioner, and a subsequent WBC of 18.6 reported to the facility without documented notification to the practitioner or triage service. The resident ultimately requested transfer to the emergency room after being informed of the lab results and was hospitalized with osteomyelitis of the sacral stage IV pressure ulcer, requiring IV antibiotics and ongoing treatment for the left and right ischial ulcers. After a later hospital stay, the resident returned with documented wound care orders for sacral and bilateral ischial ulcers, but on readmission there were no corresponding treatment orders or documented treatments for these wounds on the first days back in the facility. Additional deficiencies were identified for other residents. One resident, admitted at risk for pressure ulcer development and altered skin integrity, developed an in-house unstageable pressure ulcer when the facility failed to implement pressure ulcer prevention strategies. Another resident had failures in ensuring pressure ulcer prevention measures and care were in place, though this did not rise to the level of actual harm. Across these residents, the survey findings showed repeated failures to implement ordered wound treatments, to obtain and correctly use prescribed wound care products, to clarify incomplete orders (such as missing Dakin’s solution concentration), to consistently document and carry out preventive interventions like turning, repositioning, and heel protection, and to timely communicate abnormal laboratory findings related to wound status to medical providers.
Removal Plan
- LPN #1077 initiated skin inspection on all current residents with verifying interventions; all residents were assessed with treatments initiated for newly identified areas (Resident #11 protective dressing for loose toenail; Resident #24 non-stick pad for abdominal blister; Resident #55 bordered foam for knee abrasion).
- The residents with pressure injury treatment orders were audited by RDCS #1050 to verify EMAR orders match WCNP orders; RDCS also audited Resident #72’s wound clinic visit note and verified orders.
- The facility held an ad hoc QAPI meeting with the Medical Director #1028 (by phone) and interdisciplinary team to discuss/address the Immediate Jeopardy; nursing education was initiated following the meeting.
- DON #1057 began education for nurses and CNAs on skin prevention, daily skin care, skin inspection, documentation of refusal of nutrition/hydration, reporting and documentation; nurses were educated on implementing treatments when skin alteration identified, ensuring interventions are in place, documenting refusals, following physician/NP orders, and reporting abnormal labs same day with documentation.
- DON #1057 provided verbal education to LPNs, CNAs, and RNs; staff not reached were instructed to receive verbal education prior to next scheduled shift and a communication message was sent to staff who had not yet received education.
- Additional education was completed by DON #1057; remaining staff who were left messages will be educated prior to next scheduled shift.
- RDCS #1050 educated the clinical management team (DON #1057, LPN #1077, LPN #1078) on auditing skin prevention, interventions, order implementation, and documentation; DON #1057 will complete pressure wound measurements/assessments with MDS RN #1071 as backup.
- VPCS #1029 and RDCS #1050 reviewed the Skin and Wound Policy for accuracy and to ensure it meets regulatory guidelines.
- The clinical management team (DON #1057, LPN #1077, LPN #1078) initiated education for all licensed nurses on changes in resident skin integrity related to decline, interventions, and notification of labs to medical professionals.
- RDCS #1050 completed an audit of wound evaluations initiated since wound rounds to identify new skin areas and verify new treatments were in place (Resident #14 skin tear treated with xeroform and kerlix; Resident #6 skin tear to left shin treated with xeroform and kerlix; Resident #22 two new diabetic ulcers treated with xeroform and kerlix; Resident #94 new sacral pressure area treated with chamosyn and leave open to air).
- DON #1057/designee will audit all new admission orders for 30 days to ensure skin treatments were implemented as ordered; if DON unavailable, RDCS #1050 will audit; audit verifies each identified area has a treatment in the EMAR and is completed by DON #1057 or LPN #1077 or LPN #1078 in DON’s absence.
- DON #1057/designee will audit weekly for 4 weeks all residents seen by wound consultants/outside wound clinics to verify treatment orders match consultant orders and were implemented timely by facility nurses.
- DON #1057 educated MDS RN #1071 on auditing skin prevention, interventions, order implementation, and documentation.
- All audit results will be reported to QAPI weekly for 4 weeks.
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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