A resident with multiple comorbidities, impaired mobility, incontinence, edema, and cognitive impairment was assessed with Braden scores indicating only mild pressure injury risk, despite therapy and nursing documentation showing dependence for bed mobility and transfers, bedfast status much of the time, and frequent incontinence. The care plan was carried over from a prior admission, remained vague, and did not reflect current therapy recommendations, existing open skin areas, or wound MD involvement, while the Kardex therefore did not direct care based on the resident’s actual condition. Turning and repositioning were considered standard of care but were not documented, staff could not clearly identify responsibility for ensuring these interventions, and the dietician was not notified of the development of a Stage 3 coccyx wound or the wound MD’s request for a dietary consult. The facility’s own pressure injury prevention policy required systematic risk assessment, individualized care planning, and appropriate pressure redistribution and moisture management, but inaccurate Braden assessments, non-specific care plans, and failure to implement and document preventive interventions contributed to the resident developing a Stage 3 pressure ulcer to the sacrum.
A resident with dementia, a right femur fracture, and very high Braden risk had a right leg brace ordered to remain on with non-weight bearing, and staff were directed to remove the brace every shift for skin checks and to maintain ABD padding at the ankle and thigh. Over several days, multiple LPNs documented or observed bruising and soft skin under the brace, with no barrier between the brace and the skin, but did not notify a provider or supervisor, and some documented no abnormalities beyond baseline discoloration. A NA later removed the brace after noticing odor and moisture and discovered a large open ankle wound with exposed tendon at the brace site. Subsequent assessment by the wound physician identified this as a medical device-related Stage IV pressure injury of the right ankle, with exposed tendon and a duration of more than three days, and the physician noted he had not been informed earlier of the bruising or soft skin or of the existing padding order.
A resident with severe cognitive impairment, multiple comorbidities, high Braden risk, and existing stage 4 pressure ulcers had a care plan calling for turning, a low air-loss mattress, and heel offloading, but there was no physician order for offloading boots or for skin checks under the boots. Over several months, documentation did not show any directive to assess skin beneath the boots each shift, and a weekly skin check noted no new issues. Subsequently, an APRN and the ADON identified a new open area on the dorsal left foot, attributed by the ADON to rubbing from the boot strap, and a wound physician documented a full-thickness wound with 100% slough requiring ongoing treatment. Interviews with the APRN, the wound physician, and the ADON indicated the wound was not identified timely and that, had the boots been removed and the skin assessed every shift, the area could have been detected earlier and the wound’s progression potentially limited.
A resident with ESRD, DM2, PVD, CHF, and a sacral pressure ulcer had a care plan and MDS identifying ongoing skin breakdown risk and weekly wound measurement requirements. Although wound treatments were documented, staff repeatedly failed to record weekly wound measurements over many months, even when the resident was absent during wound rounds; the DON and an LPN stated licensed nurses were expected to complete the measurements.
A resident with quadriplegia, severe cognitive impairment, and malnutrition developed worsening pressure wounds while dependent on staff for repositioning. Documentation showed many missed NA turning/repositioning entries, the resident was repeatedly observed lying on the back instead of following the turning schedule, and the pressure-relieving mattress was set to the wrong weight. Wound measurements showed enlargement of both the sacral stage 4 wound and the right lower back unstageable wound.
A resident at risk for pressure ulcers developed a coccyx skin issue that was documented on a weekly skin assessment, but the area was not staged and no treatment order was obtained when first identified. Two days later, an LPN found an open coccyx area with drainage and redness, and a treatment order was then placed. The RN said she normally documents skin issues after weekly checks or when staff identify them during care, and the wound MD stated treatment should have been ordered when the area was first noted.
A resident with multiple sclerosis, incontinence, high pressure-ulcer risk, and recurrent moisture-associated skin damage had a care plan and physician order for a low air loss mattress set to a specific weight and checked each shift. Surveyors repeatedly observed the mattress set far above the ordered weight, despite nursing documentation indicating checks were performed. An LPN could not identify the correct setting, explain a weight sticker on the pump, or locate the information, and the facility could not provide a policy on pressure-reducing mattresses, even though an RN stated that physician orders were supposed to dictate mattress settings for residents with wounds.
Failure to Offload Heels and Follow Wound Orders: A resident with dementia, severe malnutrition, and a pressure ulcer to the left ischium was observed lying in bed without heels offloaded despite a physician order for heel elevation or foam boots. An LPN also failed to follow wound care orders by applying the wrong treatment to the left ischium, initially confusing the ischium with the hip and not applying the ordered Triad to the peri-wound area.
A resident with a reopened pressure injury did not receive a timely nutritional assessment after the wound was identified, and two residents had specialty mattresses set incorrectly instead of matching the MD orders. One resident admitted with a coccyx pressure injury also lacked a complete admission wound assessment with measurements and staging. Staff stated the charge nurse was responsible for checking mattress settings each shift, and the wound nurse and dietitian described routine wound-related monitoring that was not completed on time for the reopened wound.
A resident admitted with dementia, severe cognitive impairment, incontinence, limited mobility, and an existing heel pressure ulcer was not given a timely Braden Scale assessment or a prevention care plan on admission. Nursing notes did not show the ordered q2h turning and repositioning, and a new coccyx wound developed, progressing from a DTPI to an unstageable wound and then a stage 4 pressure ulcer. Interviews confirmed staff expected immediate pressure injury prevention measures for high-risk residents, but those measures were not implemented before the coccyx wound appeared.
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