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.
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.
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.
Incomplete Assessment of Stage 2 Pressure Injury: Facility staff failed to complete a thorough assessment of a resident’s stage 2 sacral pressure injury after it was identified on admission and again in a nurse note, with only treatment orders documented and no further pressure injury assessment recorded until a later skin check. An LPN stated nurses did not complete full weekly pressure injury assessments because they notified the wound physician, who would complete them; the wound physician did not see the resident until later for new buttock excoriation.
A resident with severe cognitive impairment, immobility, and pressure ulcer risk developed worsening wounds on the left buttock/ischium and left heel that became necrotic, malodorous, and infected. Nursing notes and surveyor observations documented foul odor, drainage, redness, warmth, eschar, and fever before doxycycline was ordered, and the heel wound was not initially assessed when hospice evaluated the resident. The record showed the wounds had progressed to advanced stages before antibiotic treatment was initiated.
Failure to Prevent and Treat Pressure Ulcers: A resident admitted without pressure injuries and with significant mobility impairment developed multiple pressure ulcers during the stay, including a stage 4 heel ulcer, a stage 3 ankle ulcer, and several unstageable wounds. The record showed pressure-injury prevention measures, nutrition recommendations, and wound care orders were not consistently documented as implemented, and staff interviews confirmed the resident required extensive assistance with turning/repositioning and developed wounds while in the facility.
Delayed assessment and treatment of a sacral pressure injury. A resident admitted with quadriplegia and a sacral wound had a baseline care plan noting a stage 2 sacral ulcer and a Braden score showing moderate risk, but the wound was not formally assessed by the WCNP until several days later. The record showed no wound care treatment before the WCNP’s assessment, and the MDS skin documentation and weekly skin assessment were also completed late. Interviews reflected conflicting staging of the wound on admission, with the WCNP describing a DTI and the DON stating the wound should have been assessed sooner.
Failure to Enter and Follow Ordered Pressure Ulcer Treatment: A resident with CVA-related hemiplegia/hemiparesis, DM2, and moderate cognitive impairment developed a sacral pressure injury that progressed from stage 2 to stage 3. The NP entered wound care orders for cleansing, Santyl, and a foam dressing, then later ordered collagen, gauze island dressing, and skin prep, but the TAR did not reflect the ordered wound care when reviewed. During observation, the wound orders had only recently been entered, and the dressing was dated the same day; when removed, the area was intact red skin and not blanchable.
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