An Iowa nursing home resident died in March after staff failed to assess or treat a pressure sore that developed over several weeks, according to a recent state inspection report. The man first exhibited signs of skin breakdown in January, but facility staff did not notify a physician or his family, nor did they begin treatment as required.
State inspectors found that a certified nursing assistant (CNA) first reported a reddened area on the resident’s coccyx in January 2025. However, the facility failed to document assessments of the area, notification to the physician, or treatment orders. By February 6, the reddened area had worsened into an open sore measuring 1 cm by 1 cm. Over the following weeks, the sore continued to progress, and the facility continued to neglect standard care protocols, according to the inspection report.
The resident was hospitalized on March 6 and diagnosed with a Stage 4 sacral decubitus ulcer and MRSA cellulitis, a dangerous bacterial skin infection. He died two days later. The death certificate listed MRSA cellulitis caused by the untreated pressure ulcer as the immediate cause of death.
The Iowa Department of Inspections and Appeals declared an “Immediate Jeopardy” situation at the facility beginning March 6. The designation was lifted on March 12 after the facility implemented corrective actions, including staff education, full-body skin assessments for all residents, daily monitoring of skin conditions, care plan updates, and the creation of a wound tracking system.
Compliance Perspective
Issue
According to F686 in the State Operations Manual Appendix PP, based on the comprehensive assessment of a resident, facilities must ensure that a resident receives care consistent with professional standards of practice to prevent pressure ulcers. A resident should not develop pressure ulcers unless their clinical condition demonstrates that they were unavoidable. Additionally, a resident with pressure ulcers must receive necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing.
Discussion Points
- Review policies and procedures related to the prevention, treatment, and healing of pressure ulcers. Ensure that these policies include the involvement of a qualified wound care provider when necessary.
- Provide staff with training on the identification of abuse and neglect, as well as protocols to prevent the development of pressure ulcers. In addition, educate staff on proper wound care to facilitate healing of existing wounds. Conduct annual competency evaluations of staff to assess their ability to perform wound care and implement preventive measures. Offer additional training where necessary to maintain standards of care.
- Periodically audit care processes to ensure that protocols for preventing and treating pressure ulcers are in place and are being followed. Review care plans to ensure they include appropriate goals and interventions related to both the prevention of pressure ulcers and the treatment of existing wounds.
*This news alert has been prepared by Med-Net Concepts, Inc. for informational purposes only and is not intended to provide legal advice.*