Failure to monitor and offload existing pressure injuries: A resident with encephalopathy, MI, and respiratory failure had stage 2 pressure ulcers to the tail bone and heel documented on admission, but no further wound monitoring was found. The care plan lacked repositioning and offloading interventions, and repeated observations showed the resident lying on their back with heels pressed on the bed and no pillows or other offloading devices in place. The resident said staff were not turning them or placing pillows under their feet, and the DON confirmed weekly assessments and pressure-reduction interventions were expected but did not occur.
Failure to assess, document, and treat pressure ulcers: Two residents had pressure injuries that were not properly monitored or documented. One resident with a pressure-related ear wound under oxygen tubing reported pain and said nursing had not assessed it; the chart had no wound assessment, provider notification, or treatment orders until surveyors identified the unstageable PU. Another resident with a coccyx PU had multiple blank TAR entries for ordered wound care, and leadership confirmed the missing documentation meant the care was not charted.
A resident with quadriplegia and significant pressure ulcers had an order for an alternating pressure-relieving mattress, but repeated observations showed the mattress remained on Static and locked instead of Alternating. Although the TAR was initialed as completed, staff interviews showed they were only checking that the mattress was plugged in and inflated, and several staff believed the settings were already programmed or could not be changed.
Failure to document and care plan a pressure injury: A resident with cerebral palsy, quadriplegia, DM, impaired cognition, and dependence for mobility developed an open area on the buttocks/thigh that progressed to a stage 3 PI. Nursing notes repeatedly described the wound as open or improving but often omitted measurements, depth, and staging, and the first measurement was not recorded until weeks after the wound was first noted. The resident’s care plan listed general skin risk but did not include the PI or specific interventions, and staff interviews confirmed the wound should have had an acute care plan and wound assessment opened when first identified.
A resident with paraplegia and mild PI risk had a physician order for a weekly foam offloading dressing to the left heel and a care plan and facility policy requiring weekly skin assessments and CNA reporting of skin changes. The dressing on the heel remained in place far beyond the ordered change interval, with an LPN admitting to peeling it back, briefly inspecting, and reapplying the same dressing without changing it or checking the date. A CNA later noticed dried fluid on the resident’s sock and alerted an RN, who found the dressing dated several weeks earlier and, upon removal, discovered an unstageable PI on the left heel that required debridement.
A resident admitted after a hip fracture with peripheral vascular disease and no pressure injuries on admission developed a right heel Stage 2 pressure ulcer that progressed to an unstageable wound with necrotic tissue and infection after staff failed to consistently implement ordered offloading and wound care. Physician and consultant orders for AFO use, heel booties in bed, heel protectors, floating the heel at all times, and increased dressing-change frequency were not reliably followed, as shown by TAR documentation and repeated observations of the resident without heel protectors while devices lay on the floor. The resident and POA reported that heel protectors were supposed to be worn at all times but were frequently not applied, and several RNs and the DON acknowledged they had not seen the wound, were unaware of some orders, or could not explain why the daily dressing-change and offloading orders were not implemented.
A resident admitted with a right heel surgical wound and a left heel DTI did not receive consistent heel offloading or wound care. The care plan called for floating both heels, but observations showed the resident repeatedly in bed with heels resting directly on the mattress, without heel boots, wedges, or pillows in place. The left heel DTI enlarged and deteriorated, and a daily betadine gauze and foam dressing order was not transcribed to the TAR.
Two residents at increased risk for pressure injuries, as identified by Braden assessments and a wound specialist, did not receive timely pressure offloading interventions or appropriate care planning, leading to facility-acquired DTPIs on both heels for one resident and a Stage 3 sacral PI for another. Despite clear recommendations for repositioning, heel floating, and use of a low air loss mattress, the baseline care plan for one resident omitted PI prevention measures, and both residents remained on standard mattresses without the ordered or requested air mattresses. One resident was observed lying in bed for prolonged periods without repositioning and was later seen in a wheelchair without proper footrests, while the other reported a painful bedsore, difficulty sleeping, and a damaged, caved-in mattress that staff had been told about weeks earlier. The DON and other staff confirmed that air mattresses were discussed and documented as ordered but were never obtained or implemented, and there was no follow-up to ensure these pressure-relieving devices were provided.
A facility failed to provide adequate PU/PI prevention and wound care for multiple residents. Care plans and Kardex entries lacked person-centered pressure offloading interventions, and staff observations showed residents lying with heels on the mattress or foot pedals without heel protection. One resident developed a right heel PU that worsened from Stage II to unstageable, and staff were observed not following the ordered wound treatment during dressing care.
Failure to implement pressure ulcer interventions and notifications: A resident with Parkinsons disease, dementia, weakness, severe cognitive impairment, and fragile skin developed a facility-acquired stage II pressure ulcer on the right buttock while sitting up in a wheelchair most of the day. Staff observed the open area and the resident reported buttock pain, but the record had no new progress note, orders, or treatment interventions, and key disciplines such as the RD, OT, restorative, and DON were not notified as expected.
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