Failure to prevent and monitor pressure injuries: A resident with leukemia, arthritis, and moderate pressure ulcer risk developed a facility-acquired unstageable DTI on the heel after the record showed no weekly skin checks, no documented turning/repositioning program, and inconsistent heel offloading, including times when the resident was observed in bed or in a recliner without heel booties and without an air mattress. The wound later showed progression, while another resident with a stage 3 pressure ulcer had missing wound measurements in the chart for multiple assessments.
Failure to prevent development of a heel pressure ulcer: A resident with CKD, HF, muscle weakness, and moderately impaired cognition was assessed as at risk for pressure injury and had care plan interventions for fragile skin, impaired mobility, and incontinence. Nursing notes documented an intact left heel blister that later progressed to a facility-acquired open area; the admin nurse verified the resident had a pressure-reducing cushion in the chair but did not have a pressure-relieving boot or other offloading interventions before the pressure area developed.
Failure to prevent a right heel pressure injury occurred when a resident with dementia, a recent hip fracture, very limited mobility, incontinence, and a Braden score showing mild risk did not have documented pressure injury prevention measures in place before the wound developed. The chart lacked evidence of heel offloading, repositioning, or other preventive interventions despite identified risk for friction and shear. Nursing later found a sore with eschar and an open blister on the heel, and the wound progressed to a painful DTI with increasing eschar.
Failure to provide ordered pressure-relieving devices and heel protection. A resident with severe cognitive impairment, diabetes, stroke-related deficits, and stage 4 heel pressure ulcers was observed without the ordered boot on one heel, while staff stated boots should be applied and maintained by CNA and LN staff. Another resident with aphasia, CVA, and a G-tube was observed in bed with both heels resting directly on the mattress despite an order for Prafo boots at all times. A third resident at risk for pressure injuries was using a wheelchair without a cushion or anti-tip devices and reported buttock pain after sitting.
A resident with incomplete quadriplegia, limited mobility, and a Braden score indicating risk for pressure ulcers developed multiple in-house acquired pressure injuries, including a worsening left gluteal ulcer and a right heel DTI. Admission and subsequent care plans called for heel offloading, pressure-reducing devices, and repositioning every two hours with two staff, but the EMR Tasks contained no scheduled turn/reposition program, no documented heel offloading tasks, and no evidence that a low air loss mattress was provided or refused. Skin and wound evaluations often omitted turning/repositioning as an additional care, daily notes sometimes reported no new skin distress despite new wounds, and there were no nutritional notes related to the wounds. CNAs reported relying solely on EMR Tasks and not on the care plan or Kardex, while nursing and administrative staff believed care plan entries would auto-generate Tasks, which did not occur. The facility’s own skin policy required preventative measures and scheduled repositioning for at-risk residents, but these were not consistently implemented or documented for this resident, resulting in the cited deficiency in pressure ulcer prevention and care.
Failure to assess and treat a present-on-admission pressure ulcer: A resident with weakness, frailty, and CHF was admitted with a Stage 2 sacral pressure ulcer, but the wound was not measured or fully assessed on admission, no photo was completed, and no wound treatment order was obtained. Nursing documentation later varied between sacrum and right buttock, and staff observed that the foam dressing was not covering the open area, with the wound showing drainage and macerated peri-wound skin.
A resident with diabetes, heart failure, muscle weakness, severe cognitive impairment, incontinence, and limited mobility was identified as at risk for pressure ulcers, with care plans calling for turning/repositioning, use of a pressure-reducing device, and extensive staff assistance for ADLs. Despite these documented risks and interventions, the resident, who preferred to remain in a recliner or wheelchair and became less mobile after a foot fracture requiring a walking boot, developed a facility-acquired Stage 2 pressure ulcer on the buttocks. Wound assessments showed the ulcer’s presence and progression over time, indicating that timely and effective preventive measures were not implemented in accordance with the facility’s wound assessment and prevention policy.
A resident with Alzheimer’s disease, depression, and chronic kidney disease returned from the ER with a right wrist fracture in a sugar‑tong splint and written instructions for the facility to call an orthopedic clinic for prompt follow‑up. Staff did not attempt to schedule the appointment for many days, then encountered an out‑of‑network issue and faxed a referral to another orthopedic provider but failed to verify receipt or follow up in a timely manner, resulting in the resident remaining in the original splint for an extended period without orthopedic oversight. At the eventual orthopedic visit, the provider documented that the facility had not followed the ER order for follow‑up and that a pressure sore had developed at the base of the thumb from the splint; a later wound note identified this as a Stage 3 pressure ulcer. Subsequent observation found the resident’s hand swollen and discolored, with the ordered dressing for the thumb wound not in place, and nursing leadership acknowledged that staff had missed the AVS instruction to call for the appointment and had delayed follow‑up after learning of network and referral issues.
A resident with dementia, impaired mobility, and documented risk for pressure ulcers returned from a hospital stay after hip fracture surgery without an air mattress, heel booties, or a turn/reposition schedule in place. Initial assessments noted no heel wounds, but the resident’s Braden scores showed at least moderate risk, and staff later reported red heels to a nurse without preventive measures being initiated at that time. The resident subsequently developed an open blister on the left heel that progressed into a full-thickness Stage 3 pressure ulcer acquired in-house, while documentation showed that pressure-relieving devices and heel-floating interventions were added to the care plan only after the wound appeared, contrary to the facility’s own skin integrity and pressure ulcer prevention policy.
Failure to prevent facility-acquired pressure injuries: A resident with multiple existing wounds, limited mobility, and a Braden score indicating pressure injury risk developed new pressure injuries to the left middle toe and left lateral foot after admission. Records showed limited weekly skin observations, inconsistent wound documentation, and no pressure-relieving boots on admission despite the resident’s risk status and need for staff assistance with turning, repositioning, and weight shifting. The resident later had necrotic tissue, swelling, redness, drainage, and discomfort during wound care.
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