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.
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 resident admitted with coccyx skin breakdown and moderate Braden risk was initially misclassified as having skin tears rather than Stage II PUs, and the skin integrity care plan lacked resident-centered interventions addressing specific risk factors such as repositioning, offloading, and moisture management. Nursing documentation over time was inconsistent, with notes alternately stating there were no wounds and describing excoriation and open areas, while weekly wound audits and evaluations were missed or incomplete. The WCC eventually identified a large unstageable coccyx PU that progressed to Stage IV, but WCC orders for twice-daily wound care, specific cleansers, and pressure-relieving devices were inaccurately transcribed on the TAR and not fully incorporated into the care plan. Weekly wound assessments were not consistently performed, and the care plan failed to document the presence and stage of the coccyx Stage IV PU or a new heel DTI, contributing to ongoing worsening of the resident’s pressure injuries.
Failure to prevent new pressure ulcers was cited for a resident who was severely cognitively impaired, had communication deficits, and was at risk for skin breakdown. The resident initially had two Stage 2 pressure ulcers that healed, but later developed two Stage 1 coccyx ulcers that progressed to two Stage 2 ulcers. Documentation noted an air overlay mattress, barrier cream, and later an air mattress, while the DON confirmed the resident’s wounds worsened during the stay.
Failure to monitor and document a resident’s right heel stage 2 pressure injury. The resident’s care plan called for weekly RN wound assessments and documentation of wound healing, but after the initial skin evaluation showed a 3.5 cm by 4 cm heel wound, subsequent weekly skin checks and progress notes did not show ongoing assessment, monitoring, or documentation of the heel wound. The wound provider followed a different wound, and the RCM and DON both stated ongoing documentation should have been present.
Failure to prevent a heel PI: A resident with diabetes, mild cognitive impairment, and multiple skin wounds was identified as being at risk for PU/PI, but the care plan did not include heel offloading interventions while in bed. Weekly skin checks documented no concerns, yet the resident was repeatedly observed with both heels resting on the mattress and with swollen, discolored, cracked feet and legs. When the feet were finally lifted, the left heel had a non-blanching purple area about the size of a quarter that staff determined was a DTPI.
Surveyors found that the facility failed to follow its own pressure injury prevention policy and professional standards for three residents at risk for or with pressure ulcers. One resident admitted with bilateral arm fractures and no PUs was identified as at moderate risk but received only one Braden assessment, had no skin or wound care plan, and later developed facility-acquired elbow ulcers that were incompletely assessed, poorly documented, and not treated with dressings for several days. Another high-risk resident with moisture, immobility, and friction/shear issues had a documented gluteal shearing wound and later a back wound that was repeatedly charted without provider notification, wound measurements, or formal wound evaluations; on hospital transfer, four wounds were present, but on readmission only one received treatment orders, and the resident was observed with an uncovered painful buttock wound, an undersized brief sitting in the wound area, and a soiled month-old dressing on the back that had not been changed or reassessed. The DON acknowledged that required Braden assessments, care planning, wound documentation, and provider/dietician notifications were not completed as expected.
A resident with impaired mobility and multiple comorbidities was admitted with blanchable redness to the buttocks and was identified as at risk for PU development, but the care plan contained only minimal interventions such as weekly skin checks and incontinence care, without individualized measures for the existing redness or documented education on repositioning or support surfaces. Despite facility policies requiring pressure redistribution mattresses, wheelchair cushions, and regular repositioning for at‑risk residents, there were no orders for a pressure‑reducing mattress or wheelchair cushion even after an outside wound care provider diagnosed an unstageable sacral PU and recommended such support surfaces. Wound care orders for cleansing, Santyl application, and foam dressings every three days were not reliably implemented, as evidenced by a dressing observed eight days after its date with moderate drainage, conflicting TAR entries, and an RN who could not recall performing the documented dressing changes or explain the outdated dressing. CNAs reported inconsistent repositioning practices and no specific documentation of repositioning, and a family member learned of the PU only after the resident complained of sacral pain, while staff interviews showed limited awareness of the PU and lack of a system to document positioning, resulting in an avoidable unstageable PU that caused pain and discomfort.
A resident with paraplegia, dementia, and severe cognitive impairment was admitted with a documented Stage 2 coccyx/sacral pressure ulcer and orders to be repositioned and have skin integrity monitored, but no wound care orders or weekly skin assessments were documented for nearly two weeks. Later notes described a Stage 2 sacral pressure ulcer and referenced a healed Stage 4 ulcer in the same area, while a wound consultant subsequently assessed a separate buttock wound as MASD and was unaware of any coccyx/sacral wound or prior Stage 4 history. Staff interviews confirmed missed weekly skin assessments, unclear documentation about whether the sacral and buttock wounds were the same, and that the resident had an open wound on the bottom since admission and often refused repositioning.
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