F0686

G

Failure to Implement and Document Pressure Ulcer Prevention for High-Risk Resident

Langhorne, Pennsylvania Survey Completed on 03-16-2026

Penalty

No penalty information released

Summary

The facility failed to timely identify and implement interventions to prevent the development of pressure ulcers for one resident, resulting in an unstageable sacral pressure ulcer. Facility policy on Skin Integrity and Wound Management required comprehensive initial and ongoing skin assessments, development of care plans based on assessment findings, and implementation and revision of interventions to prevent skin breakdown. The policy also required staff to identify residents at risk and implement appropriate prevention and treatment interventions. For this resident, the comprehensive care plan initiated on February 19, 2026, identified risk for skin breakdown and included interventions such as application of barrier cream, observation of skin for signs of breakdown, evaluation of localized skin issues, and weekly skin checks, but did not include turning and repositioning interventions.

The resident was admitted with chronic respiratory failure with hypoxia, type 2 diabetes mellitus, and vascular dementia, and was assessed with a Braden Scale score of 13, indicating moderate risk for pressure ulcer development. The MDS showed severe cognitive impairment (BIMS score of 5), dependence on staff for bed mobility and transfers, and bladder incontinence. Nursing skin assessments from February 19 through February 24, 2026, documented no skin breakdown to the sacral area. On February 25, 2026, a skin assessment documented development of an unstageable sacral pressure injury, covered with slough and/or eschar and identified as facility-acquired. A nursing progress note on February 26, 2026, documented that the sacral wound had deteriorated, measuring 7.15 cm by 8.96 cm by 0.1 cm, with slough and eschar present, seropurulent drainage, and odor after cleansing, and additional wounds were observed on the right foot.

Witness statements and interviews further described the circumstances leading up to the identification of the wound. A nurse aide reported that on February 25, 2026, during the 3:00 p.m.–11:00 p.m. shift, the resident complained of bottom pain during a bed bath; upon turning the resident, the aide and nurse observed and removed “plaster” and then saw a hole on the resident’s bottom. Another LPN reported working the night shift on February 24, 2026, and not observing any skin injury or wound, nor any turning/repositioning devices in place. The DON confirmed there were no care plan interventions addressing turning and repositioning for this resident, that the resident was on a standard pressure-redistribution mattress, and that although staff do turn and reposition residents, it is not always documented. Review of the clinical record did not show documentation or tasks/interventions indicating the resident was turned or repositioned to prevent a sacral pressure ulcer. The resident’s condition progressed to an unstageable sacral wound requiring hospitalization, with hospital records describing an open sacral wound with purulent, foul-smelling drainage and toe discoloration.