F0686

D

Failure to Implement and Document Pressure Ulcer Prevention and Treatment

Bellaire, Ohio Survey Completed on 03-17-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide timely and appropriate pressure ulcer prevention and treatment for a resident at risk for skin breakdown. The resident was re-admitted after a left hip fracture with open reduction and internal fixation and had known risk factors including peripheral vascular disease, incontinence, impaired cognition, dependence on staff for mobility and transfers, frequent urinary incontinence, and bowel incontinence. A Braden assessment completed after readmission identified the resident as at moderate risk for pressure ulcers, but there was no evidence that new preventive interventions were implemented at that time. The resident’s care plan called for weekly skin assessments and a pressure redistribution mattress, but after readmission there was no documented skin assessment until the resident’s daughter identified a coccyx skin alteration, and the resident did not have pressure-reducing devices for bed or chair, was not on a turning/repositioning program, and had no documented nutritional or hydration interventions for skin management.

The resident’s daughter submitted a concern form reporting that after the resident’s return from the hospital, the RN did not properly check the resident back into the facility and that staff were unaware of a coccyx pressure ulcer the daughter observed, which she described as several inches in size and facility-acquired. A protective dressing was first applied only after the daughter brought the ulcer to staff attention. Subsequent assessment by a consulting wound nurse practitioner documented a new in-house acquired wound on the sacrococcygeal area initially staged as a Stage II pressure ulcer with moderate serosanguineous drainage, and later facility wound documentation described the same area as an unstageable pressure ulcer with extensive eschar. The wound later cultured positive for proteus and pseudomonas, and the resident was treated with antibiotics. The wound practitioner also documented new suspected deep tissue injuries on both heels, with measurements recorded for the left heel on the day of identification and delayed documentation of right heel measurements several days later.

Treatment orders were initiated for cleansing and dressing the coccyx/sacral and buttock areas with mesalt and dry dressings daily, use of an air mattress, heel boots as tolerated, offloading, and barrier cream. However, the treatment administration record showed missed wound treatments on specific days for the coccyx/sacral area and missed heel treatments on at least one day, with no documentation that the resident refused care. Observation showed that heel boots ordered for prevention were not in place while the resident was in bed, despite no recorded refusals and staff confirmation that the boots were tolerated. The DON confirmed that staff did not administer certain ordered treatments, that the coccyx pressure ulcer was first identified by the family rather than staff, that no new interventions were implemented when the resident’s Braden score increased from low to moderate risk, and that the care plan for the pressure ulcers contained only the intervention to provide treatments as ordered, contrary to the facility’s wound and skin care policy requiring timely risk assessment, repeat skin assessment within 24–72 hours of admission, and implementation of resident-specific preventive interventions.