Failure to Prevent and Manage Pressure Ulcer Resulting in Severe Harm
Summary
A deficiency occurred when the facility failed to provide timely assessment, ongoing monitoring, and appropriate interventions to prevent the development of a pressure ulcer for a resident with arterial and venous insufficiency who was identified as being at risk for pressure ulcers. The resident, who had severe cognitive impairment, immobility, and multiple comorbidities including diabetes and peripheral vascular disease, was found with an unstageable pressure ulcer on the right malleolus beneath an ankle monitoring device. There was no immediate wound assessment, no documentation of interventions regarding skin monitoring under the ankle monitor, and no evidence that the ankle monitor had been removed. The care plan did not include interventions to monitor the skin under the ankle monitor, and physician orders for the device did not specify skin checks. The wound was not accurately assessed or measured at the time it was discovered, and there was no documentation of family or physician notification. Following the identification of the pressure ulcer, there was a lack of timely and appropriate follow-up. The wound was not assessed by a physician on the day it was found, and wound care orders were not initiated until the following day. There was no documentation that the dietitian was notified or that the resident's nutritional status was reassessed in response to the new wound. As the wound deteriorated, recommended interventions such as the use of offloading heel boots were not documented as being implemented, and a wound culture was delayed. Orders for a vascular consult and laboratory testing were not promptly carried out, and there was no documentation that the physician was notified when intravenous fluids were not administered as ordered. The resident's wound continued to worsen, showing signs of infection, and ultimately required hospitalization. The resident was admitted to the hospital with a wound infection, septic arthritis, osteomyelitis, and severe hypoglycemia. Hospital records indicated the need for intravenous antibiotics, wound debridement, negative pressure wound therapy, and ultimately an above-the-knee amputation. Throughout the period leading up to hospitalization, there were multiple missed opportunities for timely intervention, monitoring, and communication among staff, providers, and family. Documentation was incomplete regarding the implementation of physician orders, wound care interventions, and monitoring of medical devices in contact with the resident's skin.
Removal Plan
- The Administrator immediately notified Physician #600, the Interim Medical Director.
- Unit Manager Licensed Practical Nurse (UMLPN) #108 conducted a thorough assessment on Resident #05 with no adverse effects noted.
- Registered Dietitian (RD) #100 completed a nutritional reassessment for Resident #05 and updated nutritional interventions by adding an additional nutritional supplement with all meals.
- The DON and UMLPN #108 reviewed Resident #05's wound care regimen to ensure it was updated per current physician orders.
- UMLPN #108 reviewed and evaluated Resident #05's medical devices (heel boot) for proper fit and skin protection measures.
- The DON implemented an enhanced turning and repositioning schedule for Resident #05 with documentation every two hours.
- The DON and ADON #114 reviewed Resident #05's pressure redistribution surfaces as indicated by the current risk assessment.
- The DON reviewed Resident #05's current skin care plan.
- The ADON #114 reviewed the Certified Nursing Assistant's charting documentation tasks to ensure accuracy.
- The DON/designee conducted audits for all residents to identify those at risk for pressure ulcer development, with focus on residents with ankle monitoring devices or other medical devices in contact with skin. Each identified at risk resident received immediate reassessment of current interventions and implementation of enhanced monitoring protocols.
- The DON identified one current resident (#51) with an ankle monitoring device and implemented skin monitoring checks each shift.
- The DON/designee identified 33 residents with medical devices and implemented enhanced orders for skin monitoring each shift.
- The DON/designee identified 10 residents with existing pressure ulcers or a history of pressure ulcers and implemented enhanced skin monitoring orders for nurses to complete visual skin checks on shower/bath day along with a daily comprehensive skin evaluation.
- The DON/designee identified 14 residents with vascular insufficiency or other circulatory conditions and implemented enhanced monitoring orders for nurses to complete visual skin checks on shower/bed bath day.
- The DON/designee identified 34 residents at moderate to high risk of skin breakdown and implemented enhanced monitoring orders for nurses to complete visual skin checks on shower/bed bath day.
- The DON, the Administrator, and ADON #114 conducted a root cause analysis identifying contributing factors including: insufficient knowledge of ankle monitoring skin monitoring protocols, lack of standardized skin inspection procedures for medical devices, insufficient communication systems for reporting skin changes, and absence of structured investigation process for new pressure ulcers.
- The DON/designee started education for all nurses and certified nursing assistants on pressure ulcer prevention, medical device skin safety, skin and wound assessment and documentation training with emphasis on timely reporting. Nurses were also re-educated on implementation of physician orders. Education to be completed.
- The Administrator and ADON #114 reeducated RD #100 on the position job description and the importance of reassessing residents with skin integrity changes.
- The DON/designee implemented enhanced monitoring orders for nurses to complete visual skin checks on all residents on their shower/bed bath day. All new admissions will be evaluated to determine if they qualify for this classification.
- The DON/designee implemented a standardized pressure ulcer investigation form and process.
- The DON/designee implemented weekly wound care rounds with wound team participation.
- The Administrator and the Quality Assurance Team reviewed policies on medical devices with skin integrity, lab procedures and policies, and clinical documentation.
- The Administrator and Medical Director implemented new best practices on A Guide to Device Skin Inspection.
- The DON reviewed the new admission checklist and updated it to include obtaining physician orders for skin monitoring for new admissions with medical devices. The new admission checklist was implemented and put into effect.
- The Administrator notified MD #602 of Immediate Jeopardy.
- UMLPN #108 conducted a thorough skin assessment on Resident #51 with no adverse effects noted.
- The Administrator reeducated UMLPN #102 on job duties, manager role, chart review, wound care, accurate order entry, complete investigation, and follow through on all job duties.
- The facility held an ad hoc Quality Assurance and Performance Improvement (QAPI) meeting with the Administrator, Infection Preventionist/ADON #114, UMLPN #108, UMLPN #102, and Medical Director.
- The Administrator and Medical Director reviewed policies for laboratory procedures and clinical documentation. The reviewed policies were acceptable with no changes needed.
- RD #100 reviewed all residents with skin integrity changes for nutritional intervention needs.
- The Administrator/designee educated all staff on new best practices A Guide to Device Skin Inspection. Education was completed.
- The Administrator/Designee educated all nurses on laboratory communication and documentation. Education was completed.
- The DON/designee conducted a review of all residents with medical devices for skin integrity documentation. Ongoing monitoring will occur daily for five days, then five residents weekly for four weeks, then two residents monthly for two months with a completion date.
- Unit Managers/designee performed an audit of physician order implementation timeframes on all residents with new orders or order changes. Audits will continue daily for five days, then audit five residents weekly for four weeks, then audit two residents monthly for two months with a completion date.
- The DON/designee will audit random resident medical records to ensure pressure ulcer prevention interventions and skin assessments are in place as ordered. Audits by the DON/designee will continue with five random resident medical records per week for one month, then two random resident records per week for two months with a completion date.
- The DON/designee will conduct weekly audits on wound dressing changes to ensure timely treatments on five random residents for four weeks, then for five random residents monthly for two months with a completion date.
- All systemic changes would be reviewed monthly for three months by the Quality Assurance (QA) Team. The DON/designee would report monitoring plan results to the QAPI committee monthly. The QAPI committee would monitor on an ongoing basis until sustained compliance was achieved with quarterly reviews to assess effectiveness and make necessary adjustment to the monitoring plan frequency on demonstrated compliance rates.
- Staff who were not educated would not be scheduled to work until the education was completed.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident admitted with multiple comorbidities, including COPD and DM, was documented on admission as cognitively intact, needing assistance with ADLs, and having a coccyx pressure ulcer. The admitting LPN identified the ulcer but did not notify the physician or obtain wound treatment orders, instead applying barrier cream without an order. During discharge, an RN assisted with incontinence care but did not perform a full skin assessment. The resident’s representative reported not being informed of any treatment orders for the ulcer, which remained present upon transfer to another SNF. This occurred despite facility policy requiring physician-ordered wound treatments for newly admitted residents with pressure ulcers.
A resident with paraplegia, anoxic brain damage, and a Stage IV buttock pressure injury was care planned to be turned every two hours due to total dependence on staff for bed mobility and high risk for skin breakdown. On the survey day, the resident was repeatedly observed lying on his back in bed with the head elevated and no positioning devices in use, while a wedge cushion remained on a bedside table. Multiple observations over several hours showed no change in position, and the ADON confirmed the resident had not been repositioned for an extended period, demonstrating failure to follow the care plan and accepted standards of practice for pressure ulcer care.
A resident with severe cognitive impairment, wheelchair use, and a history of multiple skin issues, including prior pressure injuries, was care planned for skin integrity but developed an avoidable deep tissue pressure injury (DTPI) to the right knee associated with an undocumented knee immobilizer. After a fall and diagnosis of a right hip fracture, the resident’s right lower extremity was immobilized without a documented physician order for a knee immobilizer, and there was no evidence of skin assessment under or around the device. On readmission from the hospital, staff documented only a right knee abrasion, and no treatment orders were initiated until a wound CNP later identified a circumferential DTPI consistent with brace-related injury. Interviews confirmed no written order for the immobilizer, uncertainty about who applied it and for how long, and a delay in wound evaluation, demonstrating failures to recognize device-related pressure injury risk, monitor the device, and promptly treat the new wound.
A resident with a Stage IV sacral pressure ulcer did not receive appropriate wound care or pressure‑reducing support as outlined in the care plan and clinical guidelines. During an observed dressing change, an RN performed the ordered cleansing, packing, and redressing of the wound but failed to perform hand hygiene at any point, contrary to facility policy requiring handwashing between glove changes and before applying a new dressing. The resident was lying on a standard mattress with a visible indentation rather than a low‑air‑loss or other pressure‑reducing mattress, despite the care plan calling for such a surface and international guidelines recommending reactive support surfaces for Stage IV pressure injuries. Staff acknowledged the lack of an appropriate mattress and the resident reported discomfort and stated that a low‑air‑loss mattress had never been offered.
A resident with multiple comorbidities, total dependence for mobility and ADLs, and an existing buttock pressure ulcer did not receive timely preventive interventions such as an air mattress, pressure-relieving wheelchair cushion, or offloading despite documented risk and ulcer presence. The resident was moved from a motorized wheelchair with a pressure-reducing cushion to a standard wheelchair without adding comparable pressure-relief measures, and the comprehensive care plan initially lacked specific skin integrity interventions. Over several weeks, an LPN who was not wound certified documented weekly skin grid assessments and staged the ulcer as it worsened in size and drainage, but there was no documented RN or physician assessment or verification of staging, and no evidence of communication to an RN or physician about the ulcer during that period, contrary to facility policy and state nursing practice standards.
Surveyors found that three residents with pressure injuries did not consistently receive ordered wound care. One cognitively intact resident with a Stage 4 sacral ulcer on a specialized skin substitute trial was observed without a dressing in place, and the NP reported the dressing should remain for seven days but had come off after a shower without staff notification or prior orders for interim care. Another resident with paraplegia and a Stage 4 sacral ulcer had multiple physician-ordered dressing regimens, yet documentation showed several dates when treatments were not completed. A third resident with chronic kidney disease, diabetes, and an unstageable buttock ulcer had daily wound care orders, but MAR/TAR review showed numerous missed treatment days, all confirmed by a regional RN, contrary to the facility’s pressure injury policy.
Failure to Notify Physician and Obtain Orders for Existing Pressure Ulcer on Admission
Penalty
Summary
The deficiency involves the facility’s failure to notify the physician of an existing pressure ulcer upon admission and to obtain treatment orders for that ulcer. A resident admitted on 04/17/26 with diagnoses including COPD, diabetes mellitus, and atrial fibrillation was documented on the admission Data Collection evaluation as cognitively intact and needing staff assistance with bed mobility, transfers, toilet hygiene, and bathing. That same evaluation documented a pressure ulcer on the coccyx measuring 5.0 cm in length by 1.0 cm in width with less than 0.1 cm depth, present on admission. The only physician order on 04/17/26 related to skin/pressure management was for a low air loss mattress, and from 04/17/26 through discharge on 04/20/26 there was no documentation that the physician was notified of the pressure ulcer or that specific wound treatment orders were obtained. The admitting LPN confirmed in interview that she identified the coccyx pressure ulcer on admission, did not notify the physician, and independently applied barrier cream without obtaining treatment orders. The RN who assisted with the resident’s discharge reported helping a CNA with incontinence care and turning the resident but stated she did not complete a skin assessment prior to discharge and did not observe skin breakdown at that time. The resident’s representative reported that the resident had been admitted with a pressure ulcer acquired in the hospital, that she was not informed of any treatment orders for the ulcer while the resident was at the facility, and that the ulcer was still present when the resident was admitted to another skilled nursing facility on 04/20/26. Facility policy required that newly admitted residents be examined for existing pressure ulcers and that the physician order pertinent wound treatments, including pressure reduction surfaces, wound cleansing, debridement, dressings, and topical agents, which did not occur in this case.
Failure to Reposition Dependent Resident With Stage IV Pressure Injury
Penalty
Summary
A resident with respiratory failure, paraplegia, anoxic brain damage, and a documented Stage IV pressure injury on the buttocks was care planned to be turned every two hours due to total dependence on staff for ADLs and high risk for skin breakdown. The MDS indicated the resident was never or rarely understood and was dependent on staff for bed mobility, with pressure sores present on admission. The care plan dated 07/21/25 specified the need for repositioning every two hours as part of pressure ulcer prevention and care. On the survey date, multiple observations showed the resident lying on his back in bed with the head of the bed elevated about 30 degrees and no pillows or devices in place to offload pressure or turn him off his back. A wedge cushion was noted on a bedside table at the foot of the bed rather than in use for positioning. Observations at 10:18 A.M., 12:54 P.M., 3:09 P.M., and 5:05 P.M. consistently found the resident in the same supine position. The ADON later confirmed that the resident had not been repositioned for several hours that day, indicating the facility failed to follow the resident’s care plan and accepted standards of practice for pressure ulcer care and prevention.
Failure to Prevent and Timely Treat Device-Related Deep Tissue Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to evaluate and identify risk factors for pressure injuries, implement appropriate preventive interventions, and initiate timely treatment for a new avoidable pressure injury. The resident involved had Alzheimer’s disease with late-onset dementia, severe cognitive impairment, used a wheelchair, and was dependent on staff for lower body dressing. Her care plan, initiated shortly after admission and later revised, identified a potential for impaired skin integrity with a history of deep tissue injury to the right buttock, MASD to the buttocks, pressure injuries to both heels, and a prior area to the right knee, with goals to maintain preventive measures and avoid new skin breakdown. Interventions included minimizing pressure on bony prominences, but the facility did not identify or document the presence of a right knee immobilizer or assess the skin under or around it during the relevant period. On one date, the resident fell and was evaluated by a CNP, who ordered x‑rays of the right lower extremity and hip. The following day, documentation indicated the resident complained of pain, was to remain in bed and non‑weight bearing, and that her right lower extremity was immobilized, but there was no physician order or documentation specifying a right knee immobilizer. Physician progress notes confirmed an acute hip fracture and continuation of non‑weight‑bearing status, with no recommendation for a knee immobilizer. From the date of the fall through the resident’s subsequent hospitalization for right hip fracture repair, there was no evidence in the medical record that a knee immobilizer was ordered, applied, or monitored, nor that the skin at the right knee was assessed. Upon readmission after surgery, a progress note described a right knee abrasion with specific measurements and no depth, marked as not staged and with no mention of a pressure injury or immobilizer. The following day, a progress note documented that the resident’s daughter questioned staff about markings on the resident’s right knee from an immobilizer that had been on when the resident went to the hospital from an orthopedic appointment. The daughter reported she had not known about the brace until the surgeon called her before hip surgery to ask why the resident had a knee brace on, and the facility’s medical record contained no order for such a device. Assessment at that time revealed linear, closed indentations on the medial, lateral, and posterior aspects of the knee, and the area was scheduled for evaluation by a wound CNP two days later. No treatment order for the new area was entered until that wound evaluation, when the wound CNP documented a circumferential deep tissue pressure injury of the right knee, appearing to be from a brace, with detailed measurements and description of purple and maroon discoloration and intact, non‑blanching skin. Interviews with therapy and wound staff confirmed there were no orders for a knee immobilizer, that therapy staff may have applied an immobilizer based on a verbal request with the expectation an order would follow, and that the wound CNP did not see the resident until several days after readmission, despite the presence of the knee wound. The survey referenced National Pressure Injury Advisory Panel guidelines stating that residents should be considered at risk for pressure injury when a medical device is applied and that staff should frequently evaluate, resize, or reposition such devices, and a facility policy requiring comprehensive skin assessment and preventive planning upon admission for residents at risk.
Failure to Provide Appropriate Wound Care and Pressure-Reducing Support Surface
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate pressure ulcer care and prevention for a resident with a Stage IV sacral pressure ulcer. Record review showed the resident had multiple admissions and discharges and was cognitively intact with a documented Stage IV pressure ulcer present on admission. The care plan identified an actual skin impairment to the sacrum related to pressure and included interventions such as initiating and continuing wound treatment and providing a pressure‑reducing mattress. Physician orders directed daily wound care to the sacrum, including cleansing with wound cleanser, patting dry, lightly packing with normal‑saline‑moistened collagen, and covering with a silicone super‑absorbent dressing. A Weekly Skin Grid report documented that the sacral Stage IV ulcer, first identified months earlier, remained unhealed with full‑thickness tissue loss, exposed structures, and scant drainage. During an observed wound care procedure, the RN/Wound Care Nurse removed the old dressing, cleansed the wound, packed it with saline‑moistened collagen, and applied a new dressing without performing hand hygiene at any point, despite changing gloves. This practice did not follow the facility’s Clean Dressing Change policy, which requires hand hygiene after removing the existing dressing and gloves and again before applying the new dressing. The resident was observed on a standard facility mattress with a visible indentation where the buttocks rested, and both the RN/Wound Care Nurse and the ADON confirmed that the resident did not have an appropriate pressure‑reducing mattress, such as a low‑air‑loss mattress, despite the care plan intervention and guideline recommendations for Stage IV pressure injuries. They could not explain why such a mattress had not been offered, and the resident reported discomfort from sinking into the mattress and stated he had never been offered a low‑air‑loss mattress.
Failure to Implement Timely Pressure Ulcer Interventions and RN-Level Assessment
Penalty
Summary
The deficiency involves the facility’s failure to provide timely and appropriate pressure ulcer interventions and to complete weekly pressure ulcer assessments, including staging, in accordance with professional standards for one resident. The resident was admitted with multiple significant diagnoses, including cerebral infarction, heart failure, neuromuscular bladder dysfunction, weakness, and multiple sclerosis, and was totally dependent for bed mobility, transfers, toilet hygiene, and bathing. The resident had an indwelling catheter, an ostomy, and a documented stage IV pressure ulcer, yet the baseline care plan and activities of daily living plan identified a left buttock pressure ulcer without including preventive measures such as an air mattress, pressure-reducing cushion to the wheelchair, or offloading while in the wheelchair. The Braden Scale score indicated low risk for skin breakdown, and the physician’s admission assessment did not include an assessment of the left buttock pressure ulcer. From admission through early April, weekly skin grid pressure assessments documented a left buttock pressure ulcer that was staged as a stage II ulcer and showed progressive worsening in size and drainage. Measurements increased from 3.5 cm by 4.5 cm by 0.2 cm with minimal serosanguineous drainage to 5.0 cm by 6.0 cm by 1.8 cm with moderate serosanguineous drainage and slight odor. During this period, the resident was transferred from a motorized wheelchair, which had a pressure-reducing cushion, to a standard wheelchair for safety reasons, but there were no corresponding orders or care plan interventions for a pressure-reducing cushion on the standard wheelchair or for an air mattress overlay until early April. The comprehensive care plan initiated for risk of impaired skin integrity initially contained no interventions. The weekly skin grid pressure ulcer assessments were completed by an LPN unit manager who was not wound certified and who reported being unable to stage pressure ulcers within her scope of practice, yet she documented staging on the weekly assessments. There was no documentation in the medical record from admission through early April of communication to an RN or physician regarding the assessment, description, and staging of the left buttock pressure ulcer, and no documented RN or physician assessments of the ulcer during that time. The DON acknowledged that the LPN completed the weekly assessments and that there was no documentation of RN or physician verification of staging or assessment, and confirmed the absence of documented preventive interventions such as an air mattress and pressure-reducing cushion until orders were written in early April. Facility policies required complete, accurate, and objective documentation of assessments and services, and the Ohio Board of Nursing information cited limits on LPN practice, including that LPN care is provided at the direction of an RN, but these standards were not met in this case.
Failure to Consistently Provide Ordered Pressure Ulcer Treatments and Maintain Dressings
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered and best-practice pressure ulcer care for three residents with existing pressure injuries. One resident with multiple comorbidities, including CHF, renal insufficiency, diabetes, protein malnutrition, and a Stage 4 sacral pressure injury present on admission, had an order for a liquid protein supplement and weekly sacral wound cleansing with wound cleanser as needed and weekly. Wound notes documented a long-standing Stage 4 sacral ulcer considered stagnant, for which a skin substitute trial and specialized dressing regimen were used, with the wound NP changing the dressing weekly. During observation, the resident was found without a dressing on the sacral wound, and the NP confirmed the dressing should remain in place for seven days and that staff typically left the wound care for her weekly visit. The NP acknowledged she did not know how long the dressing had been off, staff had not notified her when it came off after a shower, and there had been no prior order directing staff what to do if the dressing detached before her visit, despite the facility policy stating that residents with wounds would receive appropriate care and nutritional support. Another resident, admitted with paraplegia and a Stage 4 sacral pressure ulcer, had a care plan intervention to perform current treatment as ordered and observe for effectiveness. Physician orders specified a sequence of sacral wound treatments over time, including cleansing with normal saline and applying various dressings (hydrofera blue, hydroconductive dressing, collagen, and silicone super absorbent dressings) on specified schedules. Review of the MARs and TARs over a six-week period showed no evidence that ordered treatments were completed on three specific dates. A regional RN confirmed that the resident’s wound care treatments were not completed as ordered. A third resident, admitted with chronic kidney disease stage 4, diabetes, and hypothyroidism, had a care plan intervention to perform current treatment as ordered and observe for effectiveness, and a physician order to cleanse a left upper buttock pressure wound with normal saline, apply medihoney and calcium alginate, cover with a dry dressing, and change daily. An observation form documented an unstageable pressure wound on the left upper inner buttock with measurable length and width. Review of the MARs and TARs for a two-week period revealed no evidence that the ordered wound care was completed on multiple specific dates. A regional RN confirmed these missed treatments. The facility’s pressure injury policy stated that residents at risk for or with pressure injuries would receive preventive interventions and care for existing injuries, but the documented omissions in wound care and lack of timely dressing replacement orders and follow-through led to the identified deficiency.
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