F0686

G

Failure to Implement Skin Care Interventions and Provide Appropriate Pressure Ulcer Treatment

Oklahoma City, Oklahoma Survey Completed on 02-18-2026

Penalty

Fine: $50,116

Summary

The deficiency involves the facility’s failure to implement care plan interventions to prevent skin breakdown and to provide appropriate treatment for existing pressure ulcers for one resident. The resident was admitted with diagnoses including an unspecified sacral fracture and abnormalities of gait and mobility, and was assessed as at risk for developing pressure ulcers, requiring assistance with rolling and perineal hygiene. The resident’s care plan, initiated on 02/05/26, included monitoring and documenting skin changes, using a pressure reducing/relieving mattress, and completing weekly skin assessments as ordered. However, skin assessments documented by the charge nurse on 02/05/26 and 02/12/26 indicated only coccyx redness and no open areas, despite subsequent findings of open wounds.

On 02/12/26, during incontinent care, the resident was observed with three open areas on the coccyx and buttocks, and a CNA applied vitamin A&D ointment to the wounds. The CNA later stated they were aware of one open spot and reported the skin issue to an RN, and asked if there was anything else to use for treatment, being told to use vitamin A&D ointment. The RN stated they did not remember being informed of the wounds and believed the resident only had redness, with their last observation occurring the previous week. The resident reported not being aware of having three wounds. A wound care nurse’s skin assessment on 02/13/26 documented three stage 2 open areas on the right buttock, left buttock, and upper buttocks, and the wound care nurse initially stated the resident did not have a wound and was not on their wound care list. Physician orders for the month showed no wound treatment orders in place.

The facility also failed to ensure the ordered pressure reducing mattress intervention was in place. On 02/13/26, the resident was observed lying on a regular mattress, and the CNA confirmed the resident did not have a pressure relieving mattress on the bed. The RN stated that all residents, including this resident, had pressure relieving mattresses, while the DON indicated that a pressure relieving mattress could mean pillows or wedges and was not aware the resident had wounds. Later, the resident was observed with a navy-blue pressure relieving mattress, and the wound care nurse clarified that the previous mattress had been a regular mattress and that not all residents had pressure relieving mattresses. The wound care nurse stated the resident’s wound would be considered facility-acquired and that having a pressure reducing mattress could have helped in preventing it.