Failure to Implement Heel Offloading, Repositioning, and Skin Assessment Leading to Stage 4 Heel Ulcer
Summary
The deficiency involves the facility’s failure to provide necessary pressure ulcer prevention and treatment services, consistent with professional standards, for a severely cognitively impaired, bedbound resident who was always incontinent and fully dependent on staff for mobility and transfers. On admission from the hospital, the resident had no heel wounds but did have a history of skin issues on the buttocks and peri-area, and the hospital’s wound care documentation included a prevention plan directing that the heels be offloaded using heel protector boots or pillows. The resident’s care plan identified her as at risk for pressure ulcers, with goals to prevent breakdown and interventions such as frequent incontinence care, bathing per schedule, weekly skin checks, and nutritional support, but it did not include specific interventions for heel offloading or repositioning every two hours. The record shows that the facility did not consistently assess and monitor the resident’s skin condition as ordered. A Braden Scale assessment was completed once, rating the resident as low risk, and no further Braden assessments were found. Physician orders dated 12/31/2025 required head-to-toe skin assessments and documentation of any changes in skin integrity on specified days, with physician notification of changes, yet there was no evidence these assessments were performed on multiple ordered dates. The EHR contained no documented Skilled Observation Notes used as skin assessments for a prolonged period, and later Skilled Observation Notes uniformly described the skin as intact with no notable changes, despite the subsequent development of heel blisters and pressure injuries. The DON later acknowledged that skin assessments were not documented in the EHR and that only changes in skin integrity were recorded in progress notes. When blisters on both heels were identified on 02/09/2026, the nurse practitioner ordered daily skin prep to the bilateral heel blisters and offloading of both heels with heel protectors while in bed. However, the MAR/TAR showed multiple shifts where heel offloading was not documented as provided, and there were several days when the ordered skin prep was not documented as applied. CNAs reported that heel protectors were sometimes removed by nurses, that the resident sometimes refused them, and that bandages were often not changed over weekends. The wound care physician, who began seeing the resident after the heel wounds developed, noted that the resident was sometimes not wearing heel protectors and attributed the wound development to immobility and general decline. By 03/10/2026, the resident’s right heel remained an unstageable deep tissue injury and the left heel had progressed to a Stage 4 pressure wound. The facility’s own skin integrity policy required repositioning at-risk residents at least every two hours and use of pillows or wedges to keep bony prominences from direct contact, but the DON later confirmed that the resident’s care plan lacked interventions for heel offloading or repositioning, and there were no orders for an air pressure mattress.
Removal Plan
- DON/ADON conducted an audit of all current residents to identify those at risk for pressure injuries (limited mobility, dependence for repositioning, malnutrition, existing wounds, recent decline); screened all residents and identified at-risk residents.
- Completed updated skin assessments on all residents and filed them in the medical record under the document tab.
- Verified pressure-relieving devices for identified at-risk residents (physician order as required, care planned, and device in place).
- Reviewed treatment orders for all at-risk residents to ensure treatment orders exist for all identified skin issues; notify MD to obtain orders when missing.
- Reviewed nutritional status for all at-risk residents to ensure nutrition assessment completed; obtain MD orders as needed; update care plan; RD review.
- Reviewed and updated care plans for all at-risk residents to address skin concerns including wounds, treatment, pressure-relieving devices, repositioning, and nutrition.
- Revised and reinforced the process for timely risk identification on admission and with condition change using the 24-hour report; DON/MDS to review every admission and condition change to ensure conditions are identified and addressed.
- Implemented weekly skin assessments completed by charge nurse with ADON auditing after completion.
- Implemented physician notification process: charge nurse to notify physician of identified skin issues; DON to audit physician notification through progress notes.
- Implemented wound consultant follow-up process: ADON to round with wound physician; ADON to implement orders and new treatments.
- Implemented care plan revision process: charge nurse/ADON/MDS to revise care plan following required change; DON to audit care plan changes.
- Implemented heel offloading process for applicable residents: charge nurse/CNAs responsible for offloading heels while residents are in bed; ADON/DON to validate using a monitoring sheet; DON to develop and maintain a list of residents requiring heel offloading.
- Re-educated licensed nurses and CNAs with post-test on pressure injury risk recognition, repositioning and offloading techniques, immediate reporting of skin changes, and documentation of skin checks on skin observation sheets; administrator to track attendance and post-tests.
- Implemented ongoing monitoring and audits by DON/ADON of residents with current pressure injuries, residents at risk for skin breakdown, repositioning documentation, weekly skin assessments, wound treatment compliance, and care plan updates.
- Correct negative audit findings immediately, including staff counseling and re-education, resident reassessment, physician notification, and care plan revision as indicated.
- Report audit findings and trends to the QAPI Committee for ongoing review and additional action if needed.
- Notified the Medical Director of the IJ and discussed and obtained approval of the plan of removal.
Penalty
Resources
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A resident with dementia, anemia, impaired mobility, and a high Braden risk score developed an in-house acquired right heel pressure injury that progressed to an unstageable ulcer with eschar, slough, malodor, and increasing size. Although a wound specialist repeatedly evaluated the wound, performed debridements, and issued updated orders to change from betadine and foam dressing to specific regimens using Vashe, medical-grade honey, and later 0.125% Dakin’s solution with dampened gauze and silicone foam adhesive dressings, staff continued to provide only the original betadine and foam treatment. Review of the TAR showed the specialist’s later orders were never implemented, and the DON confirmed the wound care recommendations were not followed, during which time the wound deteriorated and caused actual harm.
A resident with multiple comorbidities was admitted with an unstageable sacral pressure ulcer and placed on Medi-Honey dressings three times weekly. Over several weeks, the wound enlarged and remained covered with slough, but a wound specialist NP was not consulted until the ulcer had significantly worsened. When the NP did evaluate the wound, she performed debridements and ordered daily Dakin’s solution and later Dakin’s with Silvadene and calcium alginate, but the facility’s TAR showed staff largely continued Medi-Honey three times weekly, applied Dakin’s on only a few days, and never administered Silvadene. The wound progressed to a stage 4 ulcer with odor and signs of infection, later cultured positive for MRSA and diagnosed in the hospital as an infected stage 4 decubitus ulcer with osteomyelitis requiring surgical debridement, contrary to the facility’s own policy requiring timely reassessment and implementation of MD/NP-directed wound care.
Two residents at risk for or with existing pressure ulcers did not receive appropriate, individualized pressure ulcer prevention and treatment. One resident with hemiplegia, severe cognitive impairment, total ADL dependence, and incontinence developed multiple heel and ankle wounds after initial blanchable redness was noted; ordered Prevalon boots were repeatedly unavailable, the order to use them at all times was not promptly updated in the NAR, a turning schedule was not entered into the EHR, tissue analytics were missed on a scheduled date, and a nutrition consult and initiation of ordered supplements for wound healing were significantly delayed. Another resident with a stage 2 pressure ulcer was repeatedly observed on a DermaFloat LAL mattress left on the firmest setting, and the DON confirmed staff had not followed the manufacturer’s instructions to adjust and verify the mattress setting to prevent bottoming out.
A resident with an unstageable sacral pressure ulcer and hospice status had ordered daily wound care, including cleansing with normal saline, packing with calcium alginate silver, and covering with a border foam dressing. During an observed dressing change, an LPN, while wearing clean gloves, handled a pen marker from under PPE, adjusted a scrub jacket cuff to check the time, and labeled the dressing, then used the same contaminated gloved hand to pick up the calcium alginate silver and place it into the wound bed. These actions did not follow the facility’s clean dressing change policy or infection control standards for wound care.
A resident with a stage 4 pressure injury on the right lateral lumbar region did not receive wound care consistent with aseptic technique and facility policy. An LPN placed scissors and wound supplies on a PPE cart and an uncleansed bedside table, then used the same scissors to cut silver alginate that was applied directly to the wound bed. The LPN also sprayed gauze with wound cleanser and set the wet gauze on the outside of its package, which had contacted soiled surfaces, before using it in the wound care process. The DON acknowledged that these actions could contaminate the wound and were not in accordance with the facility’s pressure injury prevention and management policy requiring evidence-based treatment to promote healing and prevent infection.
Failure to assess, document, and report new pressure ulcers: A resident with a pelvic fracture and intact cognition developed stage II pressure ulcers on both inner buttocks and a new pressure ulcer on the heel. Staff interviews and record review showed the DON/wound nurse did not document the heel wound or notify the MD, did not notify the MD when the left buttock ulcer was identified, and wound monitoring was not completed daily as required by the facility's own process.
Failure to Implement Wound Specialist Orders for Unstageable Heel Pressure Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to follow wound specialist treatment orders and provide consistent, appropriate care for an unstageable pressure ulcer on a resident’s right heel, resulting in wound deterioration and actual harm. The resident had dementia, anemia, and unspecified abnormalities of gait and mobility, and a Braden Scale score of 12 indicating high risk for pressure injury. The resident’s care plan included weekly wound assessments with measurements and descriptions, provision of ordered wound treatments, and monitoring for signs of skin breakdown. A progress note documented an in-house acquired right heel pressure ulcer on January 22, 2026, but did not include measurements or a description of the wound. An order dated January 25, 2026, directed skin prep to the right heel and offloading every shift, which was later discontinued. A wound consult on January 30, 2026, described the right heel as a deep tissue injury with intact skin, dark purple discoloration, and no drainage, and recommended discontinuing current wound care orders and following new recommendations. The wound at that time measured 2.8 x 4.4 x 0 cm. On March 21, 2026, a physician order was entered to paint the right heel with betadine and cover with a foam dressing daily and as needed. Subsequent wound consults documented progression of the wound to an unstageable pressure injury with 100% lifting eschar and malodor on April 10, 2026, at which time targeted debridement was performed and new treatment recommendations were given: cleanse with Vashe solution, apply medical-grade honey gel as the primary dressing, and cover with a silicone foam adhesive dressing daily and as needed. On April 15, 2026, the wound was noted to have worsened, with 100% slough, malodor, and positive autofluorescent imaging for bacterial burden; sharp debridement was performed and new orders were given to cleanse with 0.125% Dakin’s solution, apply Dakin’s-dampened gauze, and cover with silicone foam adhesive dressing daily and as needed. Further wound consults on April 22 and April 29, 2026, continued to categorize the right heel wound as unstageable, with measurements showing increasing size, moderate exudate, malodor, well-defined margins, dry/scaly periwound, and necrotic material, with updated recommendations to continue cleansing with 0.125% Dakin’s solution, using Dakin’s-dampened gauze and silicone foam adhesive dressing daily and as needed. Review of the March and April Treatment Administration Records showed that the wound specialist’s treatment recommendations and corresponding orders from April 10 and April 29, 2026, were not implemented; instead, staff continued to provide the earlier betadine and foam dressing treatment initiated on March 21, 2026, while the wound deteriorated. In an interview, the Director of Nursing confirmed that the wound care recommendations from the wound specialist were not followed and that the resident’s wound care was never changed as recommended on April 10 and April 29, 2026. The facility therefore failed to ensure that the resident’s wound care changes were followed, resulting in harm from deterioration of the unstageable right heel pressure ulcer.
Failure to Obtain Timely Wound Consultation and Implement Ordered Pressure Ulcer Treatments
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely wound specialist involvement and adherence to ordered wound treatments for a resident admitted with an existing unstageable sacral-coccygeal pressure ulcer. The resident, a 75-year-old with multiple comorbidities including type 2 diabetes mellitus, prior necrotizing fasciitis, hemiplegia, DVT, and hypothyroidism, was admitted with an unstageable sacral pressure ulcer measuring 1.5 cm x 1.5 cm, fully covered with slough but documented as clean, without odor or signs of infection. The admission physician orders indicated the resident may be seen by a wound care physician, and the initial treatment ordered on admission was cleansing the coccyx area, applying skin prep, Medi-Honey, fluff gauze, and a dry dressing three times weekly and as needed. Despite this, the wound care nurse did not obtain a wound specialist consultation until approximately five weeks after admission, during which time the wound measurements increased and remained unstageable with slough covering the wound bed. Over the ensuing weeks, the wound care nurse documented weekly assessments showing progressive enlargement of the wound, which by early November measured 4.3 cm x 3.8 cm with excoriation around the wound and a bed fully covered with slough. The treatment administration record for November showed the resident continued to receive the same Medi-Honey treatment three times a week. The wound specialist NP first evaluated the resident on a date in early November, documenting an unstageable/unclassified pressure ulcer measuring 5.0 cm x 6.0 cm x 0.2 cm with 100% slough, moderate serosanguinous drainage without odor, and no signs of infection in the peri-wound area. The NP recommended cleansing, Medi-Honey, calcium alginate, and foam dressing three times weekly and as needed, and performed a bedside debridement to remove slough and necrotic tissue. A second debridement was performed one week later, after which the NP ordered Dakin’s 1/4 strength solution with wet-to-moist gauze and foam dressing daily and as needed. The NP later documented that Dakin’s was ordered as a debriding agent and antiseptic to help prevent infection and that daily treatment was important. Despite the NP’s subsequent orders and recommendations, the facility did not consistently implement the updated wound care regimen. The NP’s note on a mid-November visit documented the wound as now a stage 4 pressure injury measuring 6.5 cm x 4.5 cm x 2.0 cm, with moderate serosanguinous drainage and odor, 100% slough, and peri-wound signs and symptoms of infection. The NP ordered a wound culture and topical antibiotics, including Dakin’s solution and Silvadene cream with calcium alginate and foam or dry dressing daily and as needed. However, the treatment administration record showed the resident continued to receive Medi-Honey three times weekly, with Dakin’s solution applied only on three specific days and no documentation that Silvadene was ever provided. The wound nurse acknowledged that she typically received verbal orders from the NP and did not read the NP’s written notes for one to two days, and that the only change she recalled was increasing Medi-Honey frequency and later changing to Santyl. The primary physician stated he relied on consultants’ recommendations, but the record showed the resident was not seen by the wound specialist until the wound had significantly deteriorated. Ultimately, the wound culture was positive for MRSA, and hospital records documented an infected stage 4 sacral decubitus ulcer with osteomyelitis requiring operative excisional debridement of skin, subcutaneous fat, muscle, and fascia. The facility’s own wound prevention and healing policy required nurses to provide wound care per physician orders, notify the physician of lack of progress, and have the wound MD/NP evaluate and change treatment when the patient was not responding, which was not followed in this case.
Failure to Implement and Adjust Pressure Ulcer Prevention and Treatment Interventions
Penalty
Summary
The deficiency involves the facility’s failure to develop, implement, and reevaluate effective interventions to prevent pressure ulcer development and to promote wound healing for two residents at risk or with existing pressure injuries. Facility policy required Braden Scale risk assessments on admission, weekly for four weeks, then quarterly or with significant change, and mandated a systematic approach including prompt assessment and treatment, monitoring, and modification of interventions as needed. The policy also required that interventions be adjusted when risk changed, when new or recurrent pressure injuries developed, when there was lack of healing progression, or when residents were non-compliant. The Braden Scale reference used by the facility defined scores of 10–12 as high risk and 13–14 as moderate risk for pressure ulcer development. One resident with a history of stroke, right-sided hemiplegia, severe cognitive impairment, total dependence for ADLs, and bowel and bladder incontinence was identified as at moderate to high risk for pressure ulcer development on admission, with a baseline care plan including a pressure-relieving wheelchair cushion and a comprehensive care plan identifying high risk for skin breakdown. The care plan listed general interventions such as Braden evaluations, observation and documentation of skin condition, use of a special mattress, skin hygiene, and nutritional and lab monitoring. A skin check initially showed no pressure ulcers, but a subsequent skin check documented blanchable redness to the right heel. An order was in place for Prevalon boots to be worn in bed, but progress notes over several consecutive days documented that the boots were not available, and heels were instead floated on a pillow. A pressure ulcer on the right heel was then identified, and later tissue analytics showed the wound had significantly enlarged, with additional findings of a new dark area consistent with a deep tissue injury on the right heel, a new wound on the right ankle possibly related to pressure or boot straps, and a deep tissue injury on the left heel. Practitioner instructions were to protect the heels at all times, including when out of bed and to avoid resting the feet on foot pedals, but the medication/nurse administration record was not updated to reflect the “at all times” order until many days after it was given. For this same resident, the facility did not promptly obtain a nutritional evaluation for wound healing, as the dietician’s assessment and recommendation for a nutritional supplement occurred several weeks after the first pressure ulcer was identified, and the ordered supplement was not started until several days after the recommendation. Tissue analytics documentation was also not completed on one of the scheduled dates, and interviews with nursing staff confirmed that a turning/repositioning schedule was not entered into the electronic health record to cue staff, despite the resident’s high risk and existing wounds. Staff interviews further confirmed that the resident was non-compliant with Prevalon boots and that the interdisciplinary team had not re-evaluated pressure-relief interventions for the feet during this period. Another resident, cognitively intact but totally dependent for bed mobility, transfers, and personal care, and always incontinent of bowel and bladder, was assessed as at risk for pressure ulcers and already had a stage 2 pressure ulcer. This resident was observed on multiple occasions lying in bed on a Joerns DermaFloat low air loss mattress that was consistently set at the firmest setting. The manufacturer’s instructions for this mattress required individualized adjustment of the comfort setting using a hand-check method to prevent bottoming out and directed that the proper setting be documented and re-evaluated as the resident’s condition warranted. The DON confirmed that the facility had not followed the mattress manual for setup for this resident and could not confirm that the mattress was at the correct setting to prevent bottoming out as described in the manual.
Improper Infection Control During Pressure Ulcer Dressing Change
Penalty
Summary
The deficiency involves the facility’s failure to provide wound care consistent with professional standards of practice and its own policy for dressing changes for a resident with an unstageable sacral pressure ulcer. The facility’s “Dressing Change, Clean” policy required creating a clean field, using disposable gloves appropriately, and applying prescribed medication and dressings in a manner that maintains cleanliness and infection control. Resident 7’s clinical record showed an unstageable sacral pressure ulcer and hospice status, with physician orders directing daily sacral wound care that included cleansing with normal saline, packing with calcium alginate silver, and covering with a border foam dressing. During an observed dressing change for this resident, an LPN wearing clean gloves removed a pen marker from under her PPE gown, lifted the cuff of her scrub jacket to check the time, and labeled the border foam dressing, then used the same gloved hand to pick up the calcium alginate silver and place it into the wound bed. This sequence of actions showed that the same gloves used to handle personal items and clothing were then used to handle and place the wound packing material into the resident’s wound, contrary to the facility’s clean dressing change procedure and infection control standards. In an interview, the Nursing Home Administrator acknowledged that the facility’s policy should be followed for dressing changes.
Plan Of Correction
1. Resident no longer resides in facility. 2. Staff member performing dressing change educated on performing wound care/clean dressing change following surveyor identifying the concern. 3. Education provided to licensed nursing staff on wound care/clean dressing change. 4. Audit of wound care involving dressing changes by licensed nursing staff will be completed on random shifts weekly for 2 residents X1 month, then 1 resident per week X 1 month and then biweekly of 1 resident X 1month. Audits will be brought to QAPI for further recommendations for quality assurance and performance improvement.
Improper Aseptic Technique During Pressure Ulcer Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate, non-contaminated wound care for a resident with a stage 4 pressure injury on the right lateral lumbar region. The resident was cognitively intact and had a physician’s order directing that the wound be cleansed with wound cleanser or normal saline, skin prep applied to the peri-wound, followed by silver alginate to the wound base, covered with an ABD pad and secured with Hypafix tape, with dressing changes daily and as needed. During an observed wound care procedure, the LPN placed scissors, a 4x4 gauze package, and an ABD package on a PPE cart outside the resident’s room, then carried these items into the room and set them on an uncleansed bedside table. The LPN used the same scissors, which had been on the PPE cart and bedside table, to cut silver alginate that was then applied directly to the resident’s wound bed. The LPN further removed gauze from its package, sprayed it with wound cleanser, and placed the wet gauze on the outside of the gauze package that had already contacted the PPE cart and the uncleansed bedside table. After removing the resident’s soiled dressing, cleansing the wound, and applying skin prep, the LPN applied the silver alginate and ABD dressing and secured it with Hypafix tape. The LPN then placed the remaining silver alginate back into its original package and returned it to the drawer. The DON confirmed that placing scissors and supplies on the PPE cart and uncleansed bedside table, then using them on the wound, and placing wet gauze on a contaminated package could contaminate the wound, which was inconsistent with the facility’s Pressure Injury Prevention and Management policy requiring treatment and services to heal pressure injuries and prevent infection using evidence-based practices.
Failure to assess, document, and report new pressure ulcers
Penalty
Summary
The provider failed to assess, document, and notify the resident's physician of two facility-acquired pressure ulcers for one resident who had returned to the facility from the hospital with a pelvic fracture and weakness and had an intact BIMS score of 15. The resident had a stage II pressure ulcer to the right inner buttock identified on 4/6/26, and later a stage II pressure ulcer to the left inner buttock was identified on 4/27/26. The record showed wound assessments on the right inner buttock, but the report states the wound assessment documentation was not completed weekly as required, and the physician was not notified when the left inner buttock ulcer was identified. The resident was observed sitting in a wheelchair on a Roho pressure-relief cushion and stated she had an open sore on her bottom. Staff interviews confirmed she had pressure ulcers on both inner buttocks, and a CNA reported finding a new pressure ulcer on the resident's right heel that was boggy and dark red and purple in color. An LPN stated the resident had stage II pressure ulcers to both inner buttocks and that the new right heel pressure ulcer had been found the previous day. The DON/wound nurse later stated she was not aware of the right heel pressure ulcer and could not find documentation of it or documentation that the physician had been notified. The record review showed the resident's wound assessments were completed on several dates for the right inner buttock ulcer, with measurements and descriptions documented, and the care plan addressed pressure ulcers to both inner buttocks. However, the DON/wound nurse stated nurses did not monitor pressure ulcers daily and that weekly skin assessments were the routine process. The provider's policy required nurses to document and report pressure ulcers, and the change-in-condition policy required physician notification within 24 hours for a significant change of condition. The DON/wound nurse stated she did not notify the physician when the left inner buttock ulcer was identified and planned to wait until the physician rounded at the facility later.
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