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.
Surveyors found that the facility failed to promptly and comprehensively assess and treat pressure injuries for three residents on admission and readmission. One resident was admitted with a Stage 3 coccyx/buttocks pressure injury that was only minimally described, with no detailed wound characteristics documented, and no provider order for treatment obtained until two days later, with treatment not documented until the third day. Another resident with a chronic Stage 4 left gluteal fold ulcer had multiple hospital readmissions where staff documented only the wound’s location on the initial nursing evaluation, and comprehensive RN wound assessments were delayed by one to four days each time. A third resident at high risk for skin breakdown developed a sacral pressure injury that worsened significantly; after a hospital stay, this resident was readmitted with an unstageable sacral wound and a treatment order, but no comprehensive wound assessment was completed on the day of readmission, and the first detailed evaluation days later showed substantial deterioration. Interviews with the DON and wound staff confirmed that initial wound assessments and provider orders were often delayed or incomplete, contrary to facility policy requiring prompt, systematic pressure injury assessment and management.
A resident admitted with a cervical collar and no initial pressure injury developed an unstageable pressure injury on the back of the head from the collar. The care plan called for weekly skin checks and routine skin observation, but the record lacked documentation of skin checks under the device. Survey findings showed the wound was identified as a pressure wound from the rigid cervical collar, and RN H did not follow the wound treatment order during care, including omitting peri-wound skin prep and applying an ABD pad without an order.
Surveyors found that the facility failed to provide and document ordered pressure ulcer care and prevention for three residents. A resident with severe cognitive impairment and total dependence for ADLs developed an in-house Stage 2 pressure injury on the posterior thigh, but weekly and daily skin assessments and the ordered daily wound treatment were not documented on multiple days, and the wound progressed to unstageable with 100% necrotic tissue without a thorough investigation or individualized care plan revision. Another resident admitted with an unstageable right heel pressure injury had hospital discharge wound care orders that were incorrectly entered so they did not appear on the TAR, and subsequent hospital-return wound orders were also not transcribed, resulting in several days without documented treatment until the wound physician wrote new orders. A third resident readmitted with an unstageable coccyx pressure injury had no coccyx treatment ordered or implemented for several days after return, the care-planned air mattress was not ordered or placed until days later, and the resident’s heels were observed not to be offloaded despite care plan interventions.
Failure to Reposition and Document Refusals for Resident With Coccyx Pressure Injury: A resident with cognitive impairment, weakness, malnutrition, and a stage 3 coccyx/sacral pressure injury was ordered to be repositioned every 2 hours, but the record lacked documentation of ongoing repositioning or refusals. Staff stated the resident often refused to change position and preferred to lie on the back, yet no alternative offloading options were documented. Surveyors observed the resident supine without coccyx offloading, and the wound progressed, requiring ED transfer, hospital admission for fever and wound evaluation, and surgical debridement.
Two residents with existing pressure injuries did not receive care consistent with professional standards and facility policy. One resident admitted with an unstageable sacral pressure injury, later documented by a wound MD as stage 3 and then unstageable, was incorrectly down-staged as stage 2 on two separate readmissions, and staff failed to update MD orders when the wound MD changed the strength of Dakin’s solution, resulting in the wrong solution being used on two occasions. Another resident with severe cognitive impairment and an unstageable left heel pressure injury had a care plan requiring heel boots while in bed, yet was repeatedly observed in bed without heel boots and with heels resting on the mattress, even after the wound MD emphasized the need to keep the heels off the bed and staff acknowledged the resident frequently kicked off the boots and that no increased monitoring or reapproach strategy was in place.
Incomplete pressure injury assessment and treatment documentation affected two residents with existing wounds. One resident with a toe pressure injury had inconsistent weekly descriptions, missing measurements, and no documented staging, while staff gave conflicting statements about whether the wound was stageable or unstageable. Another resident admitted with stage 2 buttock pressure ulcers had an incomplete and inaccurate skin assessment, unclear wound locations, unsupported wound orders for the hip and buttocks, and staff uncertainty about the number and site of the wounds.
Failure to Provide Consistent PI Care and Skin Monitoring: The facility did not consistently prevent or treat pressure injuries for three residents. One resident at very high risk did not receive timely heel offloading or weekly comprehensive PI measurements, another had heel wounds that were not staged and lacked consistent assessment documentation, and a third had recurrent skin breakdown without current treatment orders, weekly comprehensive skin assessments, or documented provider notification. Staff and DON/ADON interviews confirmed gaps in assessment, staging, and individualized interventions.
A resident with multiple comorbidities, high Braden risk score, incontinence, and a history of resolved pressure injuries had physician orders and a care plan requiring an air mattress with function checks every shift, consistent with the facility’s pressure injury prevention policy. Over multiple observations on two days, the surveyor noted that the resident’s Proactive Protek Aire 8000 pump had no lights on and was not functioning while the resident lay in bed on his back with the head of the bed elevated. An LPN confirmed that air mattresses for residents who have them should be on but had not noticed the pump was off, and an RN/Unit Manager described expected checks of air mattress function; however, no additional explanation was provided by leadership for the ongoing lack of air mattress function.
A resident with a significant history of prior sacral ulcer repair, flap surgery, skin grafting, ESRD on dialysis, diabetes, morbid obesity, and limited mobility developed a facility-acquired unstageable pressure injury. The facility assessed the resident as low risk, did not document the prior pressure injury surgical history in the care record, and relied on general skin precautions and a pressure-redistribution cushion. When the wound was found, staff documentation was inconsistent about whether it was on the right buttock, left sacrum, or sacrum/buttocks, and the wound RN and APNP later described a much larger unstageable area than the initial nursing measurement.
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