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.
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.
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