F0686

D

Failure to Provide Timely Pressure Ulcer Assessment, Treatment, and Prevention

Cheswick, Pennsylvania Survey Completed on 04-03-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide necessary pressure ulcer treatment and preventive services consistent with professional standards for two residents, and failure to prevent the development of new pressure ulcers for one of them. For one resident admitted with malnutrition, stroke, hypertension, and a stage 3 pressure ulcer on the left buttock, the Braden Scale assessment dated on admission was left blank and incomplete, and no pressure ulcer risk care plan was initiated upon admission. Although a wound consultant later documented a stage 3 left buttock ulcer with specific treatment recommendations, including cleansing, application of medical-grade honey, and preventive measures such as turning/repositioning and moisture management, these recommendations were not incorporated into the physician orders from the date of the consultant’s assessment through the following week. The clinical record also lacked evidence that the recommended preventive measures were care planned, and weekly wound measurements were missing for at least one week, despite documentation that the wound was larger and stalled during that period.

The same resident’s care plan for pressure injuries was not initiated until 21 days after admission, even though the resident had an existing stage 3 pressure ulcer and was at risk due to comorbidities, immobility, and incontinence. Wound assessments over time showed that the left buttock ulcer increased in size and was described as stalled before later being documented as stable and improving. The wound consultant confirmed that there were no measurements documented for the week in early January and that the medi-honey treatment recommended in mid-December was not implemented. The Nursing Home Administrator and other administrative staff acknowledged that the facility failed to timely implement wound care treatment recommendations, failed to document weekly assessments for the stage 3 ulcer during the identified week, and failed to ensure Braden assessments were accurately completed and a pressure ulcer risk care plan was initiated in a timely manner.

For a second resident, admitted with a right humerus fracture and other diagnoses including prior fractures, lung mass, muscle weakness, and hypertension, the admission nursing assessment documented no wound concerns and a Braden score of 19 (not at risk), and did not note the right humerus fracture, sling use, or limited mobility. Occupational therapy notes shortly after admission documented that the resident was non-weight bearing to the right arm and had impaired safety awareness, and the resident was observed with a sling, but there were no physician orders for a sling or for skin checks under and around the sling until later. The initial care plan identified risk for pressure ulcers due to decreased mobility and called for skin inspections every shift, but did not specify checking the skin under and around the sling. Skin check records showed intermittent documentation of “skin clear” and redness, with several days missing and no evidence of skin inspection every shift or specific checks under the sling.

Subsequently, the resident’s son reported concerns about an open wound and the state of the sling, and staff then identified a large open pressure injury to the right elbow with reddened skin. Nursing notes from that time did not include a comprehensive assessment or wound measurements, and there was no additional Braden scale completed to reassess risk after the wounds were found. Within days, new deep tissue injuries and pressure areas were documented on the right ankle and heel, and later wound assessments by a consultant identified an unstageable right elbow pressure injury and additional pressure injuries on the right lateral heel and malleolus. Physician and PA documentation did not initially include wound measurements, and subsequent care plans after these pressure areas developed did not include the new pressure areas, a plan to check skin under and around the sling, or interventions related to healing the new pressure areas. Interviews with therapy, nursing, and wound care staff confirmed that the resident had a sling on admission, that expectations included checking skin under the sling, and that there were no early sling or skin-check orders, supporting the finding that the facility failed to prevent the development of pressure ulcers and to provide necessary treatment and services in accordance with professional standards.

The surveyors concluded that the facility failed to ensure residents were provided necessary treatment and services to prevent and treat pressure ulcers, failed to complete accurate Braden assessments, failed to initiate timely care plans for pressure ulcer risk and existing wounds, failed to implement wound consultant treatment recommendations in a timely manner, and failed to conduct and document appropriate and consistent skin assessments, including under medical devices such as slings. These failures were cited under 28 Pa. Code: 201.29(a) Resident Rights, 28 Pa. Code 211.10(c)(d) Resident Care Policies, and 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.