Staff failed to ensure ordered heel off-loading devices and protectors were available and in use for a resident with a documented stage 4 heel pressure ulcer and multiple areas of impaired skin integrity. During observation, no heel devices were present in the room or on the bed. A CNA reported that none were on the resident’s heels at the start of her shift, and an LPN could not locate the devices despite stating the resident had heels up and booties. The LPN also stated the resident refused the devices and that providers should be notified of refusals, while the resident reported that staff had removed the devices previously to give to someone else. Clinical records, including the MDS and weekly wound evaluation, documented the need for off-loading the heels and use of specialty devices, which were not in place.
A resident with quadriplegia, chronic respiratory failure, a tracheostomy, and existing Stage 3 and Stage 4 pressure injuries, fully dependent for ADLs and severely cognitively impaired, developed a new pressure injury on the left upper arm after a tourniquet was left in place following IV initiation for antibiotic therapy. Facility staff and an external IV team placed peripheral IVs in both arms, and a lab phlebotomist later drew blood from the left hand, but there was no documentation that the tourniquet used during these procedures was removed. Several days later, a CNA discovered the tourniquet still around the resident’s left upper arm during ADL care, and an RN observed swelling, redness, denuded skin, and blisters encircling the arm. The wound was documented as a new, in-house–acquired, device-related pressure injury, initially unstageable and later staged as Stage 3. Interviews revealed that routine bathing and gown changes that could have exposed the tourniquet earlier were not completed, and staff acknowledged that the wound was preventable and related to the prolonged presence of the tourniquet and lack of thorough skin assessment.
Staff failed to obtain and initiate timely treatment orders and a baseline care plan for a dependent, vegetative resident admitted with a known sacral/coccyx pressure area. Admission and subsequent skin assessments documented a sacral maceration and later an unstageable pressure ulcer with necrosis and slough, yet no wound treatment orders were in place for the first five days after admission, despite facility policies requiring skin assessments and treatments as needed. Wound care orders, including a wound-healing supplement, weekly skin checks, and sacral cleansing and dressings, were only started later, after the ulcer was already documented as unstageable.
A resident admitted with cellulitis and chronic leg ulcers had pressure injuries to both buttocks identified on admission and confirmed on body audit as DTIs with maroon/purple tissue. The record did not show wound treatment before the orders and eTAR entries began, despite staff stating that admission nurses should review discharge instructions, obtain orders if needed, and document treatment in the eTAR and care plan.
Staff failed to prevent the development of a sacral stage 3 pressure ulcer in a cognitively impaired, highly dependent resident with multiple comorbidities and documented risk for impaired skin integrity. The care plan called for monitoring pressure areas, turning and positioning, and assisting the resident to bed during the day for pressure relief, but observations showed the resident remaining in a wheelchair for many hours on multiple days, largely to accommodate a spouse’s preference for dining room meals. Skin assessments progressed from no issues to MASD on the sacrum and then to an open sacral wound, which was later staged by a wound care physician as a stage 3 pressure ulcer of pressure etiology. The DON reported relying on staff assurances that weight shifting occurred in the wheelchair, and there was no indication that the responsible party was educated about the need for pressure offloading, while the resident was also observed receiving no encouragement or assistance with meals.
Incomplete Assessment of Stage 2 Pressure Injury: Facility staff failed to complete a thorough assessment of a resident’s stage 2 sacral pressure injury after it was identified on admission and again in a nurse note, with only treatment orders documented and no further pressure injury assessment recorded until a later skin check. An LPN stated nurses did not complete full weekly pressure injury assessments because they notified the wound physician, who would complete them; the wound physician did not see the resident until later for new buttock excoriation.
Failure to Prevent and Treat Pressure Ulcers: A resident admitted without pressure injuries and with significant mobility impairment developed multiple pressure ulcers during the stay, including a stage 4 heel ulcer, a stage 3 ankle ulcer, and several unstageable wounds. The record showed pressure-injury prevention measures, nutrition recommendations, and wound care orders were not consistently documented as implemented, and staff interviews confirmed the resident required extensive assistance with turning/repositioning and developed wounds while in the facility.
A resident with multiple comorbidities and a history of pressure ulcers was re-admitted with intact skin but did not receive consistent weekly skin assessments or have a care plan addressing pressure ulcer prevention. Facility staff failed to document or implement preventive interventions such as regular repositioning and use of pressure-relieving surfaces until after two advanced-stage pressure injuries were discovered during a facility-wide skin sweep. Documentation for turning and repositioning was inconsistent, and required assessments and care planning were not completed as per facility policy.
A resident with multiple comorbidities was admitted with an unstageable pressure ulcer, but staff did not perform a comprehensive wound assessment or initiate treatment orders until several days later. Despite facility policy requiring prompt evaluation and intervention, nursing staff failed to document wound details or contact providers for care, resulting in a lack of timely wound management until a wound NP intervened.
A resident with an open sacral wound was not thoroughly assessed or treated upon admission due to a failure to document the physician's order in the treatment administration record. For several days, the wound was not monitored or treated as required, and daily assessments failed to identify the presence of a pressure injury. The deficiency was confirmed through record review and staff interviews.
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