Failure to Clean and Monitor a Pressure Injury: The facility failed to promote healing of a resident’s unstageable DTI to the right ischium. During wound care, the DON applied treatment without cleaning the wound first, despite staff and the wound physician stating that cleansing with saline or wound cleanser was appropriate. The record also lacked weekly nursing assessments documenting the wound’s location, stage, size, and description, and the facility relied on intermittent wound physician visits that were missed when the resident was at dialysis or out of the facility.
A resident was repeatedly observed lying in bed with O2 tubing around the ears and no ear protectors in place. An LPN later confirmed the resident should have had the protectors, but they were still not being used after the issue was brought to her attention. Facility guidance stated that evidence-based pressure injury prevention interventions should be implemented and communicated to relevant staff.
A resident assessed at moderate risk for pressure injuries developed in-house acquired heel, sacral, and buttocks wounds after ordered prevention measures were not consistently implemented. The record showed a pressure-reducing mattress and wheelchair cushion were ordered, but they were not documented on the treatment record for months, and wound physician off-loading recommendations were not carried out on the care plan or TAR. During wound care and interview, the resident's heels were observed not being off loaded until an LPN later placed a pillow under the legs, and the wounds were later documented as worsening and infected.
Staff failed to ensure ordered heel off-loading devices and protectors were available and in use for a resident with a documented stage 4 heel pressure ulcer and multiple areas of impaired skin integrity. During observation, no heel devices were present in the room or on the bed. A CNA reported that none were on the resident’s heels at the start of her shift, and an LPN could not locate the devices despite stating the resident had heels up and booties. The LPN also stated the resident refused the devices and that providers should be notified of refusals, while the resident reported that staff had removed the devices previously to give to someone else. Clinical records, including the MDS and weekly wound evaluation, documented the need for off-loading the heels and use of specialty devices, which were not in place.
Failure to accurately assess and classify an open wound for a resident with stroke, L hemiplegia, impaired cognition, and significant ADL dependence. Nursing notes documented worsening sacral and buttock skin breakdown, including an unstageable sacral eschar and later progression of superficial skin damage to an unstageable area. The CCC stated she was the primary wound assessor, had no formal education in wound staging or root cause analysis, and believed the sacral wound was caused by pressure but complicated by moisture.
A resident with quadriplegia, chronic respiratory failure, a tracheostomy, and existing Stage 3 and Stage 4 pressure injuries, fully dependent for ADLs and severely cognitively impaired, developed a new pressure injury on the left upper arm after a tourniquet was left in place following IV initiation for antibiotic therapy. Facility staff and an external IV team placed peripheral IVs in both arms, and a lab phlebotomist later drew blood from the left hand, but there was no documentation that the tourniquet used during these procedures was removed. Several days later, a CNA discovered the tourniquet still around the resident’s left upper arm during ADL care, and an RN observed swelling, redness, denuded skin, and blisters encircling the arm. The wound was documented as a new, in-house–acquired, device-related pressure injury, initially unstageable and later staged as Stage 3. Interviews revealed that routine bathing and gown changes that could have exposed the tourniquet earlier were not completed, and staff acknowledged that the wound was preventable and related to the prolonged presence of the tourniquet and lack of thorough skin assessment.
Pressure ulcer care interventions were not implemented as ordered for two residents. One resident with a stage 4 pressure ulcer had an air mattress and wound vac set incorrectly, and an RN confirmed the settings were not right. Another resident had an order and care plan for an alternating pressure mattress, but the mattress was not in place for 18 days even though staff documented it as present; an LPN stated signing the record means the treatment or device was in use, and the ADON confirmed the mattress was not actually in place.
Staff failed to obtain and initiate timely treatment orders and a baseline care plan for a dependent, vegetative resident admitted with a known sacral/coccyx pressure area. Admission and subsequent skin assessments documented a sacral maceration and later an unstageable pressure ulcer with necrosis and slough, yet no wound treatment orders were in place for the first five days after admission, despite facility policies requiring skin assessments and treatments as needed. Wound care orders, including a wound-healing supplement, weekly skin checks, and sacral cleansing and dressings, were only started later, after the ulcer was already documented as unstageable.
A resident admitted with cellulitis and chronic leg ulcers had pressure injuries to both buttocks identified on admission and confirmed on body audit as DTIs with maroon/purple tissue. The record did not show wound treatment before the orders and eTAR entries began, despite staff stating that admission nurses should review discharge instructions, obtain orders if needed, and document treatment in the eTAR and care plan.
Staff failed to prevent the development of a sacral stage 3 pressure ulcer in a cognitively impaired, highly dependent resident with multiple comorbidities and documented risk for impaired skin integrity. The care plan called for monitoring pressure areas, turning and positioning, and assisting the resident to bed during the day for pressure relief, but observations showed the resident remaining in a wheelchair for many hours on multiple days, largely to accommodate a spouse’s preference for dining room meals. Skin assessments progressed from no issues to MASD on the sacrum and then to an open sacral wound, which was later staged by a wound care physician as a stage 3 pressure ulcer of pressure etiology. The DON reported relying on staff assurances that weight shifting occurred in the wheelchair, and there was no indication that the responsible party was educated about the need for pressure offloading, while the resident was also observed receiving no encouragement or assistance with meals.
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