A resident with a sacral pressure ulcer, malnutrition, and neurologic deficits was admitted and later readmitted with multiple wounds, but the admission and readmission skin assessments did not include wound measurements or adequate descriptions. The resident’s coccyx wound was later found to be worsening with black slough, heavy purulent drainage, foul odor, and increased pain, and the hospital documented a larger full-thickness sacral wound with exposed tissue and bone. Interviews confirmed the facility expected admission wound descriptions and measurements, but those were not completed.
A resident with a sacral pressure ulcer received wound care using a tap-water-moistened washcloth placed on the wound before a foam dressing was applied, even though the DON stated wounds should be cleansed with a wound cleanser or soap and water. The resident also had a specialty mattress in place, but staff were unsure of the proper setting and check frequency, and the EMHR contained no provider orders for the mattress setting or how often it should be verified.
Failure to prevent and monitor pressure injuries: Three residents with significant risk factors had pressure injury prevention measures not implemented or not monitored as ordered. One resident developed DTI to both heels and the air mattress was set incorrectly; another developed buttock pressure ulcers that worsened to stage 3 after missed turning documentation and delayed use of a Roho cushion; a third resident’s air mattress was set incorrectly and ordered heel boots were left in a recliner instead of being worn in bed.
Pressure ulcer care, risk scoring, and wound treatment failures. Staff failed to follow ordered wound treatments, accurately score Braden assessments, and consistently implement skin protection measures for multiple residents with dementia, PVD, ESRD, diabetes, quadriplegia, incontinence, and existing wounds. Records and observations showed missed or delayed treatments, absent or inconsistent heel protection, incomplete skin monitoring, and worsening pressure injuries, including one resident who developed septic shock and required surgical debridement of a stage 4 sacral ulcer.
A resident with multiple comorbidities, including DM, CHF, PVD, COPD, and a recent hip fracture, had a Braden score indicating risk, but no heel pressure injury prevention interventions were documented and weekly skin checks were not completed. The resident later developed a right heel stage III pressure ulcer, and wound care was not provided as ordered when an LPN found a saturated dressing that had not been changed as scheduled and did not complete all ordered wound care steps, including skin prep and gauze wrap.
Failure to implement pressure relieving boots for a resident with pressure ulcers. A resident with TBI, hemiplegia, limited ROM, and memory problems had a stage 3 pressure ulcer to the right foot and later developed a new DTI to the right foot near the toe. The care plan called for a pressure relieving/reducing device, but the TAR initially had no boot order, and later documentation showed no use of the Prevalon boots; when observed in bed, the boots were in the wheelchair. The DON confirmed the boots were not initiated until after the stage 3 ulcer developed.
Failure to Prevent Pressure Injury Development: A resident with dementia, CKD, and major mobility dependence developed a heel pressure injury after the facility did not implement documented pressure prevention measures. Records showed only limited monitoring and shoe changes, while turning/repositioning and heel-floating were not entered into the care plan or orders. Observations found the resident’s heels flat on the mattress, and the pressure redistribution mattress was placed in the wrong direction, with staff confirming they had not been educated on proper placement.
Failure to prevent and address pressure ulcer development: A resident identified as at risk for skin breakdown developed an in-house acquired unstageable L heel wound, yet the care plan did not address the existing ulcer or include interventions to prevent additional pressure injuries. Observations showed the resident’s feet pressed against the bed footboard, heels resting on a recliner footrest crossbar, and no offloading in place for the R foot; an RN confirmed no interventions were in place to prevent additional pressure ulcers.
Two residents at risk for or with existing pressure ulcers did not receive appropriate, individualized pressure ulcer prevention and treatment. One resident with hemiplegia, severe cognitive impairment, total ADL dependence, and incontinence developed multiple heel and ankle wounds after initial blanchable redness was noted; ordered Prevalon boots were repeatedly unavailable, the order to use them at all times was not promptly updated in the NAR, a turning schedule was not entered into the EHR, tissue analytics were missed on a scheduled date, and a nutrition consult and initiation of ordered supplements for wound healing were significantly delayed. Another resident with a stage 2 pressure ulcer was repeatedly observed on a DermaFloat LAL mattress left on the firmest setting, and the DON confirmed staff had not followed the manufacturer’s instructions to adjust and verify the mattress setting to prevent bottoming out.
Surveyors found that the facility failed to follow its own skin and wound management policy for two residents at risk for pressure ulcers. One resident returned from the hospital with multiple documented unstageable pressure ulcers on the right foot and ankle, but the facility did not obtain or document treatment orders, did not include these wounds in weekly skin assessments, and provided no wound treatments for 13 days. Another resident with impaired mobility and documented DTIs to both heels did not have timely care plan updates or treatments initiated as first documented, later developed an unstageable ulcer on the bottom of the right foot without corresponding orders or TAR entries, and was observed on an air mattress set for more than double the resident’s weight while wearing heel protectors that did not offload the heels as ordered. Staff interviews confirmed incorrect support surface settings, use of the wrong heel devices instead of ordered Prevalon boots, and failure to transcribe and carry out treatment orders for the new foot ulcer.
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