Failure to Reposition Dependent Resident With Stage IV Pressure Injury
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.
Penalty
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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 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.
A resident with multiple comorbidities and a stage 3 sacral pressure ulcer on admission did not receive timely and complete pressure ulcer care and prevention. The baseline care plan omitted any wound care interventions, and a comprehensive pressure ulcer care plan was delayed by 10 days. Although a physician ordered sacral wound care with Triad twice daily, documentation showed the treatment was not started for three days. There were no orders or care plan directions for turning/repositioning until 10 days after admission, and the plan did not specify frequency. A pressure redistribution mattress was not ordered until several days after admission and was applied later. These actions and omissions occurred despite a facility policy requiring risk identification, repositioning at least every two hours, and use of pressure redistribution mattresses as indicated.
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 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.
Failure to Timely Implement and Document Pressure Ulcer Treatment and Prevention
Penalty
Summary
The deficiency involves the facility’s failure to provide timely and complete pressure ulcer care and prevention for a resident admitted with a stage 3 sacral pressure ulcer. The resident had multiple diagnoses including cerebral infarction, dysphagia, diabetes, morbid obesity, sepsis, bipolar disorder, anxiety disorder, hypertension, osteoarthritis, and peripheral vascular disease, and was incontinent of bowel and bladder with impaired short- and long-term memory and orientation to self only. On admission, the resident had a documented stage 3 sacral pressure ulcer measuring 0.6 x 0.3 x 0.2 cm, yet the baseline care plan, completed days later, marked wound care as not applicable and contained no interventions related to pressure ulcers. A comprehensive pressure ulcer care plan was not implemented until 10 days after admission. Although a physician ordered sacral wound care with normal saline cleansing and Triad application twice daily and as needed on the admission date, the TAR showed no evidence that this treatment was initiated until three days later. The record further showed that the resident required substantial/maximal assistance with turning and was always incontinent, but there were no physician’s orders for turning/repositioning and no care plan or profile card addressing turning/repositioning until 10 days after admission, and even then the plan did not specify the frequency of repositioning. A pressure redistribution mattress was not ordered until three days after admission and was documented as applied the following day, after the resident refused to get up. The facility’s own pressure injury policy required identification of residents at risk, implementation of preventive interventions such as repositioning at least every two hours, and use of pressure redistribution mattresses as indicated. The Regional Nurse Consultant confirmed that the initial assessment and baseline care plan failed to identify the existing pressure ulcer or required care, that the treatment was not provided for three days after being ordered, and that turning/repositioning was not included in the resident’s care plan during that period.
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