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 perform hand hygiene between glove changes during wound care. An LPN changed dressings on a resident with multiple pressure injuries, including a heavily draining, odorous buttock wound, an unstageable coccyx ulcer, and a left heel injury, but repeatedly removed dirty gloves and put on new gloves without cleaning hands in between. The LPN said she only washed her hands before starting and after finishing, while the DON stated hand hygiene was required each time gloves were changed during wound care.
A resident with multiple comorbidities and limited mobility developed a worsening right gluteal wound that progressed from an abrasion to an infected Stage 4 pressure ulcer with foul odor, purulent drainage, and sepsis requiring hospital transfer and surgical debridement. Staff documentation showed the wound deteriorated over time, but the facility could not show that the MD was properly notified of the changes or that timely action was taken. A left heel area also lacked documented treatment or prevention measures, and surveyors later observed a dark red/black area on the heel while the resident’s heels were flat on the bed.
Failure to Document and Measure Pressure Ulcer Weekly: A resident with a Stage 2 pressure ulcer, hospice status, impaired cognition, and significant care needs had a physician order for twice-weekly dressing changes and weekly wound measurements. Facility records showed multiple weeks with no wound documentation or notes that lacked wound description or measurement, despite the facility’s policy requiring weekly monitoring and detailed documentation of the ulcer, pain, mobility, treatments, and wound characteristics.
Failure to monitor and offload existing pressure injuries: A resident with encephalopathy, MI, and respiratory failure had stage 2 pressure ulcers to the tail bone and heel documented on admission, but no further wound monitoring was found. The care plan lacked repositioning and offloading interventions, and repeated observations showed the resident lying on their back with heels pressed on the bed and no pillows or other offloading devices in place. The resident said staff were not turning them or placing pillows under their feet, and the DON confirmed weekly assessments and pressure-reduction interventions were expected but did not occur.
Failure to complete and document ordered wound care for two residents with significant comorbidities and skin risk factors. One resident with ESRD, CHF, DM, and multiple foot wounds had repeated missing TAR entries and no progress note documentation for ordered dressing changes, and was later hospitalized with worsening wound infection and osteomyelitis after the wound care provider reported concern that the facility was not changing dressings as ordered. A second resident with DM and CKD had ordered sacral and heel wound care, but the record lacked skin assessment details, wound measurements, and descriptions of the wounds.
A resident with significant neurologic impairment, malnutrition, and dependence on staff developed a facility-acquired lower back pressure injury that progressed to a stage 4 wound with infection, sepsis, and surgical debridement. Surveyors observed prolonged time in the same position, a nonfunctioning air mattress, delayed meal assistance, and missing turning/repositioning documentation. Records and interviews also showed the wound worsened over time, with inadequate offloading noted in hospital documentation.
Failure to Perform Hand Hygiene During Wound Care
Penalty
Summary
The facility failed to perform hand hygiene between glove changes during pressure ulcer wound care for one resident who was cognitively intact, required substantial to maximal assistance with transfers, and had diagnoses including a thoracic vertebra fracture, muscle weakness, and right lower leg amputation. The resident was identified as being at risk for pressure ulcers and had wound orders for the left heel, right buttock, and gluteal crease. The wound assessment described a right upper buttock pressure ulcer measuring 5 cm by 6.5 cm by 2 cm with odor and heavy purulent dark brown drainage saturating the dressings, an unstageable coccyx pressure ulcer, and a deep tissue injury on the left heel with a drained blister and intact epidermal layer. During observed dressing changes, the LPN removed soiled dressings from the right buttock and gluteal fold, then removed dirty gloves and put on new gloves without performing hand hygiene. She repeated this pattern after cleaning the wounds and again while changing the left heel dressing, removing gloves and donning new gloves without hand hygiene before removing the old dressing, cleaning the heel, and applying the new dressing. The LPN stated she washed her hands before starting and after the dressing change, but did not think to perform hand hygiene when changing gloves. The DON stated nurses were to follow wound procedures during dressing changes, including hand hygiene each time gloves were changed, and that hand hygiene was done to ensure the wound does not become decontaminated when placing clean dressings.
Failure to Manage Worsening Pressure Ulcers and Document Physician Notification
Penalty
Summary
The facility failed to obtain orders and implement interventions for one resident with pressure ulcers, and the resident’s right gluteus abrasion deteriorated into an infected Stage 4 pressure ulcer. The resident was admitted with diagnoses including major depressive disorder, atrial fibrillation, obesity, osteoarthritis, and a left heel pressure ulcer. The resident was cognitively intact, required substantial to maximal assistance to roll in bed, and was dependent on staff for transfers. The care plan and MDS identified pressure ulcer risk and included interventions such as turning and repositioning every 2 hours, pressure relief devices, heel floating, weekly skin assessments, and wound specialist involvement. The right gluteus wound was first identified as an abrasion and was treated with ordered dressings, but serial skin issue reports documented progressive deterioration, increasing size, pain, drainage, odor, and slough. The wound was described as non-healing and later as unstageable, with purulent drainage and foul odor. Staff interviews showed that changes in the wound were often placed on reports or left on the physician’s desk, but the facility was unable to provide reproducible evidence that the physician was notified of the worsening wound or what response was given. The wound nurse practitioner stated she was not notified of deterioration between follow-up visits and that earlier notification could have allowed more aggressive treatment. The wound continued to worsen until the resident required bedside and then surgical debridement, IV antibiotics, and hospital transfer for shock and sepsis related to the infected pressure ulcer. Hospital records documented a Stage 4 buttock pressure wound with polymicrobial infection and sepsis due to the pressure ulcer. In addition, a left heel area noted by wound evaluation as callous-like skin with blanchable erythema and possible pressure component did not have documented treatment orders or preventive measures in the resident’s record, and later survey observation found a dark red/black closed area on the left heel while the resident’s heels were lying flat on the bed.
Failure to Document and Measure Pressure Ulcer Weekly
Penalty
Summary
The facility failed to follow physician orders and its pressure ulcer documentation policy for a resident with a Stage 2 pressure ulcer on the thoracic spine. The resident’s quarterly MDS identified moderately impaired cognition, substantial assistance needs for care, bed mobility, and transfers, hospice status with a life expectancy of 6 months or less, pain that had been severe during the assessment period, and use of scheduled and as-needed pain medication. The resident also had a pressure relieving device in the chair and on the bed. During an observation, an RN performed a dressing change, removed the old dressing, cleansed the area, and measured the wound at 0.7 cm x 0.4 cm; the RN described it as superficial with a red wound bed and well-defined edges and stated weekly wound documentation was completed in the progress notes. The physician’s telephone order directed staff to change the dressing to the thoracic spine twice weekly and measure the wound on Tuesdays until healed, while the facility’s pressure ulcer protocol required weekly monitoring and documentation of the ulcer’s location, stage, length, width, depth, surrounding tissue, wound bed, pain, mobility, current treatments, and active diagnoses. Review of the nursing progress notes showed five weeks in which the facility did not follow the order to measure weekly or document the pressure ulcer assessment per policy, including periods with no wound documentation or notes that lacked a description or measurement of the wound. Interviews with nursing staff and the DON confirmed the expectation that the wound should be assessed and measured weekly and documented in the progress notes.
Failure to Monitor and Offload Existing Pressure Injuries
Penalty
Summary
The facility failed to provide care and services to monitor actual pressure injuries and to prevent new pressure injuries for one resident who was reviewed for pressure injuries. The resident was admitted with diagnoses including encephalopathy, myocardial infarction, and respiratory failure, and was able to make needs known. During an interview, the resident stated that their sitting bones were sore. The resident was later sent to the hospital and returned to the facility. The admission nursing assessment documented a 6 cm by 10 cm stage 2 pressure ulcer to the tail bone and a 3 cm by 2 cm stage 2 pressure ulcer to the left heel, but no further monitoring of the pressure injuries was found in the EHR. A body check assessment did not list the pressure injuries, although it noted pressure ulcer prevention measures including pillow, offloading, and turning and positioning. The active plan of care showed the resident had declined a low air loss mattress, but no other interventions such as offloading and repositioning were listed. Multiple observations showed the resident lying on their back in bed with no offloading devices and heels pressed on the bed. The resident stated staff never put pillows under their feet or turned them on their side. Staff interviews confirmed that residents with pressure injuries should have positioning devices, frequent repositioning, weekly monitoring, and care plan interventions, but these were not in place for this resident.
Failure to Document and Complete Ordered Wound Care
Penalty
Summary
The facility failed to complete ordered pressure ulcer and wound care for two residents who were at risk for skin breakdown. One resident had multiple diagnoses including CKD, CHF, HTN, ESRD, muscle wasting/atrophy, anemia, and was cognitively intact with a BIMS score of 15. That resident required substantial to maximal assistance with toileting, was incontinent of urine and bowel, had two foot ulcers, a diabetic foot ulcer, and a wound infection, and was assessed as at risk for pressure ulcer development. For that resident, physician orders included daily wound care to the left calcaneus, right calcaneus, right plantar foot, and right medial foot, along with topical povidone-iodine to the right foot. The TAR for 5/2026 did not document completion of the ordered wound care on multiple dates, and the progress notes also lacked documentation that the treatments were completed on those dates. The resident’s hospital history and physical documented worsening wound infection, multiple wounds in both feet with significant purulent drainage and necrosis, and the resident reported that the nursing home should have been changing wound dressings daily but said that was not done. The wound care provider stated she was concerned the facility was not completing the dressing changes as ordered and sent the resident to the emergency room, where the resident was admitted with osteomyelitis of the right foot. The second resident had diagnoses including type 2 DM, stage 4 CKD, anemia, and HTN, and had a BIMS score of 15. The resident’s care plan identified risk for skin complications, and physician orders included daily wound care to the sacrum and right heel using wound cleanser, Medi honey, and bordered gauze. However, the nursing admission observation had no documentation that the skin was assessed, the nursing admission assessment documented skin conditions requiring monitoring/treatment without measurements, locations, or descriptions, and the skin assessment documented no new findings without documenting the current areas. There was no documentation of wound measurements or descriptions from 1/15/26 through the resident’s discharge to the hospital on 2/25/26.
Pressure Ulcer Care and Offloading Failure
Penalty
Summary
Failure to provide appropriate pressure ulcer care and prevent new ulcers from developing was identified for one resident who had multiple risk factors, including hemiplegia/hemiparesis following cerebral infarction, aphasia, vascular dementia, protein-calorie malnutrition, and dependence on staff for repositioning, transfers, dressing, hygiene, and eating. The resident’s MDS reflected she was at risk for pressure ulcers and was not on a turning/repositioning program at earlier assessment points. The resident later returned from the hospital with a stage 4 pressure ulcer and continued to have a facility-acquired wound on the lower back/spinal area that was documented as unstageable/deep tissue injury and later progressed to a stage 4 pressure ulcer with exposed bone and undermining. Record review showed the wound was first documented as a new in-house pressure ulcer on the lower back with erythema, edema, slough, and eschar, and subsequent notes described worsening size, depth, undermining, pain, and seropurulent drainage. The resident was hospitalized for sepsis secondary to an infected stage 4 lumbar pressure ulcer with deep soft tissue infection, and hospital records noted surgical debridement. Infectious disease documentation stated the lumbar decubitus ulcer was associated with likely spinous process erosion in the setting of inadequate offloading and recommended aggressive offloading and nutritional supplementation. Survey observations showed the resident remained in the same bed position for extended periods, with a wedge under the hip and the bed alarm/beeping noted, while meal assistance was delayed and the resident called out for food. On another observation, the air mattress pump was not functioning and the mattress appeared deflated, with the resident sunk into the bed. Staff interviews and record review also found missing turning/repositioning documentation, and the facility could not provide a complete investigation when requested. The resident’s care plan included turning/repositioning, pressure-reducing devices, and skin checks, but the report documented that the resident’s wound developed and worsened while these measures were not consistently evidenced in the record or during observations.
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