The facility failed to provide physician-ordered daily wound care for three residents with Stage II–IV pressure ulcers to the sacrum and heel. Each resident had specific orders for daily cleansing, application of Santyl and/or Collagenase, use of calcium alginate, and coverage with silicone foam border dressings, with changes every day and as needed. Treatment records showed that ordered wound care was not completed on multiple consecutive days, and dressings observed in place were dated several days earlier. The treatment nurse, LPNs assigned on those days, the DON, and a contracted wound care NP all acknowledged that the daily pressure ulcer treatments were not performed as ordered.
A resident with severe cognitive impairment, CHF, type 2 DM with circulatory complications, morbid obesity, impaired mobility, and wheelchair use had physician orders and a care plan intervention for a pressure-reducing seat cushion every shift due to high risk for pressure ulcers. On the survey day, the resident was observed twice seated in a wheelchair without the ordered cushion. A CNA and an LPN both stated the resident required two-person assistance, was at risk for pressure ulcers, and had an order for a pressure-reducing cushion, yet confirmed no cushion was present in the wheelchair or the room. The DON verified that the cushion should have been in use whenever the resident was out of bed in the wheelchair.
Two residents with existing pressure ulcers and high risk for skin breakdown did not receive ordered pressure-relief interventions and scheduled repositioning. One resident with multiple comorbidities and a Stage 2 heel ulcer had a care plan and posted signage requiring heel protectors, yet surveyors repeatedly observed the resident in bed or in a specialized wheelchair with heels on the mattress and the heel protectors stored on top of a closet; a family member reported never seeing them applied, and nursing staff acknowledged they should have been in use. Another resident with paraplegia, bilateral above-knee amputations, and Stage 4 buttock ulcers was care planned for a q2h turn schedule with wedges, but was repeatedly observed lying on his back with no supportive equipment while the wedges remained unused in a box; the resident stated staff did not turn or offer to turn him, and the assigned CNA and DON later acknowledged that q2h turning should have been provided but was not.
A resident with severe cognitive impairment, multiple sclerosis, hemiplegia, and a Stage 4 sacral pressure ulcer had physician orders and a care plan for sacral wound care three times weekly and as needed when soiled. During an observed treatment, a treatment nurse removed a saturated sacral dressing and completed the ordered wound care while leaving a soiled brief in place, then secured the same soiled brief on the resident afterward and replaced the bed linens. The nurse acknowledged the brief was soiled during treatment, and the DON stated the brief should have been changed before and not left on after the wound care, contrary to the facility’s pressure injury prevention policy requiring residents to be kept clean and dry.
Nursing staff failed to document the date and their initials on wound dressings after treatments for two residents with pressure ulcers, and did not use dressings large enough to fully cover and protect a wound for one resident. Observations and staff interviews confirmed that dressings were missing required documentation and, in one case, did not fully cover the wound, leaving it exposed.
A treatment nurse did not follow required hand hygiene and glove change protocols during wound care for a resident with severe cognitive impairment and multiple medical conditions. The nurse failed to remove gloves and perform hand hygiene at key steps, as outlined in facility policy, during a pressure ulcer dressing change. This was confirmed by both the nurse and the DON during interviews.
A resident did not receive appropriate care for existing pressure ulcers, and preventive measures to avoid new ulcers were not consistently implemented. The facility did not follow established protocols for assessment, monitoring, and treatment of pressure ulcers.
A resident with multiple risk factors for pressure ulcers, including immobility and a history of skin impairment, was observed multiple times without a pressure-reducing cushion in the wheelchair as required by the care plan. The DON confirmed the absence of the cushion, despite its documented necessity for pressure ulcer prevention.
A resident with hemiplegia and moderate cognitive impairment, identified as at risk for pressure ulcers, was left on a deflated air-loss mattress for over eight hours. Despite the resident reporting air escaping and a low air pressure warning being visible, staff did not physically check the mattress's inflation. The issue was later traced to the CPR function being activated, but the resident remained on the improperly inflated mattress for an extended period, contrary to the care plan and facility policy.
A nurse failed to perform hand hygiene when changing gloves and between the treatment of multiple pressure ulcers for a resident who was fully dependent on staff and had several complex medical conditions. The nurse believed hand hygiene was only necessary between residents or if hands were visibly soiled, a misunderstanding confirmed during interviews. The DON acknowledged that proper hand hygiene should have been performed during the wound care process.
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