F0686

G

Failure to Prevent and Manage Pressure Ulcers for a High-Risk Resident

Arkoma, Oklahoma Survey Completed on 03-13-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to prevent the development and worsening of pressure ulcers for one resident with known skin integrity risks. The resident’s baseline care plan noted existing skin integrity issues and ordered zinc cream to the bottom twice daily for prevention of skin breakdown. An admission assessment later documented that the resident was severely impaired in daily decision making, dependent for rolling from side to side, and at risk for pressure ulcer development, with no pressure ulcers present at that time. Despite these identified risks, a nursing progress note shortly thereafter documented a new, in‑house acquired stage 2 pressure ulcer to the left gluteus, with exposed dermis and specific wound measurements, and the family, physician, and wound nurse were notified.

Subsequent documentation showed evolving and additional pressure ulcers and gaps in wound management. A care plan for impaired skin integrity included interventions such as use of positional devices, a therapeutic air mattress, monitoring skin integrity every shift, notifying the physician for treatment orders, and continuing an every‑hour turning schedule. However, the wound care company’s clinical schedule did not show the resident as being seen on one of the dates they were in the facility, even though the pressure ulcer had already been identified. When the wound care company nurse practitioner eventually assessed the buttock wound, it was classified as unstageable with larger dimensions than initially documented, and the practitioner could not determine if the wound was improving or worsening. A later nursing skin evaluation documented a new, in‑house acquired unstageable pressure ulcer to the left ankle.

Physician orders were written for specific wound treatments and for the resident to be turned every hour from left to right only, but the electronic health record task tab for two subsequent months showed the resident was not repositioned every hour as ordered. A CNA stated that prevention for this resident consisted of repositioning every hour and that documentation of repositioning was in the task tab, but could not recall other interventions. The physician reported that they did not treat pressure ulcers or write wound care orders, stating that the wound care company managed wounds, and denied writing the wound care order dated 12/07/25. The wound care nurse practitioner stated they treated wounds weekly and assessed the resident’s pressure ulcer on 12/19/25, without recalling prior notification. The DON confirmed that the wound care company was present on multiple dates and that the resident’s pressure ulcer was identified before one of those visits, but the resident was not seen by the wound care company on that earlier visit, and also confirmed that documentation did not show the resident was turned and repositioned every hour as ordered.