Failure to Provide Ordered Pressure Ulcer Care and Offloading: Two residents with multiple pressure injuries had worsening wounds while ordered wound care was missed or not completed as directed. Surveyors observed soiled or undated dressings, an uncovered sacral wound with drainage and necrotic tissue, inconsistent use of pressure-reducing boots, and an LAL mattress set at varying weights while staff showed inconsistent understanding of offloading and mattress settings.
Improper LAL Mattress Settings for Residents With Pressure Ulcers: Three residents with pressure ulcers were observed on LAL mattresses set far above their documented weights, including settings at 220 pounds, 308 pounds, and the highest setting past 300 pounds. One resident had a worsening Stage IV ischial ulcer with infection and osteomyelitis, another had multiple pressure ulcers with drainage and undermining, and a third had a history of Stage III heel and foot ulcers with a reddened heel noted during observation. The DON, wound physician, and medical director stated the mattresses should be set to the resident’s weight or manufacturer guidelines.
Failure to timely assess and document pressure ulcers led to worsening wounds for two residents. One resident with dementia, lupus, immobility, incontinence, and hospice care developed a new sacral wound that was not properly assessed, documented, or reported for days, progressing to a Stage 4 ulcer with exposed bone and probable osteomyelitis. Another resident with Alzheimer’s disease, CKD, and existing pressure injuries had multiple new skin breakdown areas, but staff communication, documentation, and wound treatment follow-through were inconsistent, including missed assessments and unclear completion of ordered care.
A resident at high risk for pressure injury developed a new wound on the right buttock that was reported by a hospice aide to an LPN, but the LPN did not measure it, document it, or notify the MD. Facility records showed missed skin assessments and no timely documentation of the change, and the wound was not entered in the chart until later as a pressure ulcer with slough and surrounding discoloration. Hospice staff reported the resident was often wet and soiled and that the wound appeared worse over time.
Failure to provide and document ordered wound care for a resident with a stage 4 sacral pressure ulcer and a right heel wound. The resident reported that after an incontinent episode the sacral dressing was removed and not replaced, and that the right ankle/heel wound had not been changed for several days. Observation found the sacral area uncovered with dried stool present, and the heel dressing still dated from several days earlier with dried drainage and adherence to the wound. The TAR showed wound care documented as completed even when the treatment had not been done.
A resident with impaired cognition, reduced mobility, chronic pain, diabetes, and identified risk for pressure injury developed an in-house Stage 2 pressure ulcer on the left buttocks. The physician ordered the wound to be cleansed, treated with TAO, and covered with a border gauze dressing BID, but observation found the wound open to air without a dressing. An LPN reported using barrier cream and keeping the wound open to air, while the DON stated the wound should have TAO and a bandage. The resident’s care plan did not reflect the presence of the Stage 2 pressure ulcer, and the care plan process had not been updated to include this new wound.
Staff failed to consistently document and follow physician‑ordered wound care for a resident with a Stage 3 sacral pressure ulcer, with multiple missed entries on the TAR for daily sacral treatments. Another resident, who was severely cognitively impaired and fully dependent for mobility, had orders and a care plan requiring being laid down after meals and use of heel protectors and positioning wedges for pressure relief. Observations showed this resident repeatedly sitting in a mechanical chair with bare heels pressed into the footrest and heel protectors left unused in the room, with no repositioning over an extended period. A subsequent skin assessment identified a new, facility‑acquired Stage 1 pressure injury on the resident’s heel, and interviews with CNAs and an RN confirmed they were unaware of the orders for heel protectors and positioning between meals.
A resident with a coccyx wound had missed ordered treatments and worsening breakdown, another resident with multiple stage 3 and 4 pressure ulcers had saturated or dislodged dressings and a low air loss mattress set at a 500-lb setting despite weighing 117 lbs, and a third resident at high risk for skin breakdown had a mattress set to 320 with normal pressure without a physician order for the setting. The DON and wound nurse described gaps in monitoring mattress settings and following ordered wound care, while observations documented soiled bedding, compromised dressings, and ongoing wound drainage.
Failure to identify and monitor pressure ulcers: A resident with hemiplegia, incontinence, contractures, and impaired mobility had repeated weekly skin checks that did not fully assess or document a heel wound and toe wound. Staff entered a treatment order for the left ankle/heel area but did not consistently document wound care or progress notes, and the DON was not aware the wounds were pressure ulcers until the wound NP first evaluated them and found a stage 3 heel ulcer and an unstageable toe ulcer.
Failure to identify, assess, and relieve pressure on residents with wounds: Two residents with diabetes, limited mobility, and heel wounds were observed with their heels and toes pressed against the mattress, pillow, or footboard, and one resident developed a new dark purple indented area on the great toe while wound care was being performed. The IP/Wound Nurse and LPN documented wounds as diabetic or pressure-related at different times, while a resident’s heel wound worsened and another resident’s heel remained unprotected in a recliner with the heel pressed into the footrest. The report also noted wound care hand hygiene/glove changes were not followed consistently during treatment.
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