F0686

D

Failure to Prevent and Adequately Offload Sacral Pressure Ulcer

Fort Belvoir, Virginia Survey Completed on 03-18-2026

Penalty

No penalty information released

Summary

Facility staff failed to provide necessary care to prevent the development of a sacral stage 3 pressure ulcer in one cognitively impaired, highly dependent resident. The resident had Alzheimer's disease, heart failure, diabetes, severe impairment in daily decision-making (BIMS score 3/15), and required substantial to maximal assistance for most self-care and mobility tasks. The care plan identified a potential for impaired/compromised skin integrity related to bilateral lower extremity edema and incontinence, with interventions including observing pressure areas for redness, notifying the nurse of any redness, encouraging and assisting with turning and positioning, assisting the resident to bed during the day for pressure relief, and assisting with repositioning as needed. A low-air-loss mattress was not added until late February.

Weekly skin assessments initially documented no skin issues on 2/4/26, with barrier cream used on both buttocks as a preventative measure due to incontinence. By 2/11/26, nursing documentation identified moisture-associated skin damage (MASD) on the sacrum, which continued to be documented on 2/18/26. On 2/22/26, nursing documentation described an open wound to the sacrum measuring 2 cm x 2 cm, which was not staged at that time but was cleaned with normal saline and covered. When the wound care physician first evaluated the resident on 2/24/26, the sacral wound was identified as a stage 3 pressure ulcer of pressure etiology, measuring 2.0 cm x 1.5 cm x 0.2 cm, with 100% granulation tissue and moderate serous drainage, and treatment with calcium alginate with honey was ordered.

Despite the resident’s high risk for pressure injury and the presence of a sacral pressure ulcer, observations on multiple days showed the resident remaining in a wheelchair for extended periods. On 3/11/26, the resident was observed in a wheelchair in her room at approximately 11:00 AM and again at 3:50 PM. On 3/12/26, the resident was observed in bed at about 9:15 AM with breakfast, then out of bed in a wheelchair at 11:07 AM being taken to the dining room, and again in the wheelchair in her room at approximately 4:30 PM. On 3/18/26 at about 11:00 AM, the resident was again observed sitting in a wheelchair in her room. A CNA reported that the resident was out of bed daily before 11:00 AM because the spouse wanted the resident to have lunch in the dining room. The DON stated that direct care staff had assured her they shifted the resident’s weight when seated in the wheelchair, but there was no indication that the nursing team had educated the responsible party or power of attorney about the need to offload pressure to promote healing and prevent additional pressure ulcers, while the resident was also observed receiving no encouragement or assistance from staff with meals.