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.
A resident who was unable to make themselves understood and required extensive assistance with mobility and ADLs was admitted with a documented sacral pressure ulcer. Facility policy required that wound care be provided per physician orders and that a physician be notified to obtain treatment orders when none were present. Despite this, the resident’s records showed no physician order for treatment of the sacral ulcer, and an RN confirmed that the physician had not been notified and that no treatment order had been obtained.
Two residents with existing pressure injuries and complex medical conditions were found lying on pressure-relieving air mattresses that were not calibrated to their documented weights, despite care plan interventions and orders requiring proper inflation and monitoring. One resident with severe cognitive impairment, multiple open wounds, MASD, and several Stage 3 and unstageable pressure injuries had a weight of about 154 lbs, but the mattress was set to 180 lbs. Another resident with moderate cognitive impairment, diabetes, neuropathy, and a Stage 3 pressure injury to the right buttock weighed about 197 lbs, yet the mattress was set at the maximum setting of 380 lbs. An RN confirmed in both cases that the mattresses should have been set according to each resident’s weight and that incorrect settings could contribute to skin breakdown.
Failure to Implement Pressure Injury Prevention: A resident with a hip fx, PVD, lymphedema, foot drop, limited mobility, and a Braden score indicating pressure injury risk developed a left heel pressure injury after the facility did not have pressure-reducing interventions in place. Records showed no turning/repositioning task or skin-related care plan interventions until after the heel blister was found, and staff later observed the resident seated with both heels resting on wheelchair footrests.
The facility failed to properly assess and document pressure injuries for two residents, including limited wound measurements and incomplete tracking of wound healing or decline. One resident developed a stage 3 pressure injury after earlier buttock skin changes and heel wounds were noted, while another resident had buttock pressure injuries that later reopened after being documented as healed. Staff also observed a low air loss mattress left on the firm setting for one resident, and an LPN was observed cleansing wounds in a manner that did not follow the facility policy.
Failure to prevent worsening pressure injury care occurred for a resident with TBI, dementia, COPD, and CHF. A coccyx skin breakdown progressed from a small open area to a heavily draining, foul-smelling sacral wound with eschar, undermining, and infection, later described by the wound clinic NP as effectively a Stage 4 pressure injury. The record showed limited interventions beyond barrier cream, dressing changes, and repositioning, and the DON stated there were no additional interventions besides repositioning and wound care.
A resident with quadriplegia, amputations, a Stage III sacral pressure ulcer, multiple venous ulcers, and a surgical wound was care planned for a low air loss mattress, but there was no corresponding physician order or usage parameters. The mattress alarm beeped for weeks, indicating malfunction, yet staff, including an LPN and the IDON, did not know how to correct or calibrate it and key personnel were not notified of the problem. Observations showed the mattress set at the highest weight setting despite the resident’s much lower recorded weight, and the mattress was calibrated based on comfort rather than manufacturer-recommended weight-based settings, contrary to the device instructions.
Two residents at risk for pressure ulcers did not receive consistent prevention, assessment, or wound management in accordance with facility policy. One resident with quadriplegia and moderate cognitive impairment had no documented weekly skin evaluations for a two-week period after admission, did not receive pressure-reducing surfaces until after a stage 2 buttock ulcer developed, and later developed additional pressure ulcers without timely measurements or new care plan interventions; this resident’s air mattress was repeatedly set for a much higher weight than recorded, with no practitioner order for the mattress or its settings. Another resident, cognitively intact but with incontinence and decreased mobility, had a history of heel and foot ulcers and was care planned for weekly skin monitoring, yet went 11 days without a documented weekly skin evaluation before hospital transfer; hospital records then identified a full-thickness posterior thigh wound with purulent, malodorous drainage and additional pressure ulcers to the heel and top of the foot that were not fully captured in facility documentation. Staff interviews confirmed missed weekly skin evaluations, lack of identified causal factors for certain wounds, and uncertainty about whether treatments were in place prior to hospital transfer.
Incomplete pressure ulcer monitoring and documentation: A resident with bilateral heel pressure ulcers had weekly wound assessments completed by the DON/wound nurse, but the records repeatedly documented only a single length measurement and did not include width or depth as required. The resident’s heel wounds were described as open, with one heel still showing drainage on observation, and the DON confirmed the wounds were measured as a diameter rather than by length and width.
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