Ftag of the Week – F686 Treatment/Svcs to Prevent/Heal Pressure Injuries (Pt. 2)

Last week in the first part of our “Ftag of the Week” for F686, CMSCG Consultant Mary Quinn provided information on key definitions and staging considerations. This week on the CMSCG Blog, we are reviewing assessment and prevention of pressure injuries.

Assessment and Prevention of Pressure Injuries

In order to prevent a resident from developing a pressure injury, their risk factors need to be determined via the comprehensive resident assessment. A formal risk assessment tool is a good way to identify some – but not all – risk factors.

The Braden scale is a common risk assessment tool used by many facilities and common practice is to complete the tool weekly x 4 at the time of admission/readmission. Regulatory guidance in Appendix PP shares information related to research that shows the 80% of PU/PIs develop withing 2 weeks of admission and 96% develop within 3 weeks of admission.

Regulatory guidance in Appendix PP shares information related to research that shows the 80% of PU/PIs develop withing 2 weeks of admission and 96% develop within 3 weeks of admission.

The ongoing assessment and subsequent score are meant to be used to develop resident-specific interventions for pressure injury prevention/treatment and should be completed on an ongoing basis to capture changes in a resident’s risk level. Typically, the Braden is completed as above, as well as quarterly with the MDS schedule. It is also completed with any development of a new ulcer and/or significant change.

Remember – Not all risk factors may be addressed on the formal tool and all existing and potential risk factors need to be evaluated.

So, you thought you did due diligence and initiated appropriate preventative interventions, but the resident developed a pressure injury- what went wrong?

Avoiding Potential Problems

Hot spots to think about- before not after – the development of an ulcer!!

  • Risk factors for development of pressure injuries not addressed in medical documentation.
  • Not addressing changes to a resident’s clinical condition/acute illness. i.e., resident with exacerbation of COPD, CHF with new need for continuous oxygen develops a PI from the oxygen tubing- new risk factor not addressed.
  • No evidence of resident education related to shifting position when OOB to chair.
  • Lack of monitoring of equipment – i.e., Roho in use – inflation/adjustment not monitored
  • Lack of equipment replacement – heel booties laundered multiple times resulting in loss of function

Standard Survey Citation F686 S/S: D

A surveyor observed a resident whose legs appeared to be contracted in bed. The surveyor observed a heel boot on the resident’s nightstand. Shortly after, the surveyor returned to the resident’s room and observed a lack of off-loading support on the resident’s heels. The following day, the surveyor stopped by the resident’s room and saw that the resident did not have heel boots or off-loading support in place for her heels. The facility was cited for failure to follow a physician’s order to offload a resident’s heels.


  • Refusals/non-compliance – i.e., resident refused multiple showers – weekly skin check by the nurse not conducted, resulting in no documentation of ongoing skin assessment
  • Resident non-compliance not documented i.e., resident repositions on their back after caregiver provides turning and positioning per plan of care
  • Family takes resident for frequent out of pass- aware of risk factors/instruction provided as indicated?
  • Low air loss mattress in use but not set appropriately to the resident’s current weight.

Standard Survey Citation F686 S/S: D

During observation, a surveyor saw that a resident was on an air mattress, however, the air mattress was not on and functioning. An alarm on the mattress was sounding, and an Aide entered the resident’s room, and silenced the alarm on the pump. On interview, the Aide stated she would notify a nurse that the alarm was sounding. The surveyor returned to the room two additional times in the next few hours and heard the alarm beeping, as well as a red-light indicator on the air mattress pump. Staff interviewed stated no one had alerted them about the issue with the pump and a work order would be put in to have it inspected. The facility was cited for not ensuring that an air mattress was functioning properly and adequately inflated for a resident with a history of wounds who was receiving hospice care.


  • Omissions of documentation- turning and positioning activated but incomplete or shows repeated positioning on the same side.
  • Clarification not obtained to determine if devices can be removed/opened for skin inspection- i.e., splint in use post fracture-Velcro straps not opened/skin inspected

Standard Survey Citation – Immediate Jeopardy – F686: S/S: K

A facility was cited for failure to prevent an avoidable pressure ulcer when it was identified that the facility missed 24 opportunities to complete ordered skin assessments under a resident’s leg brace. Substandard Quality of Care (SQC) was identified at F686, and the facility was placed in Immediate Jeopardy. The resident had recent right leg fractures that were inoperable, so the resident was admitted to the facility with a knee immobilizer from home. The hospital discharge summary did not include instructions on whether the immobilizer could be removed during care or not. The resident’s physician order included checks for skin breakdown every shift. Staff inaccurately documented the orders as for the left leg, versus the right, resulting in an initial lack of skin checks being completed, but after that was corrected, only the skin around the brace was checked for breakdown, not under the brace. This resulted in an unstageable wound that was discovered during wound rounds after skin checks had not been performed appropriately for approximately two weeks.

Interesting, if you did not note it, but this IJ was cited at a Pattern scope/severity not isolated.


  • Lack of monitoring of the POC – Contractures – intervention for hand splint –- device not applied – pressure injury development related to pressure from fingernails
  • Resident refusal of device – without documentation of alternative being offered – education/risks/benefits
  • Room changes without all equipment being brought with the resident.

Standard/Complaint Survey Citation F686 S/S:D

A facility was cited for failure to ensure a resident receives care, consistent with professional standards of practice, to prevent pressure ulcers after a surveyor observed that a resident at risk for pressure ulcers did not have an air mattress in place as ordered. Nursing documentation on multiple shifts indicated that the air mattress was in place. The resident had been transferred from one room on the same unit to another a few days prior to survey. A work order was put in for the mattress to be moved when a staff member realized it was not in the resident’s room. 

My question is whether it was possible to relocate the bed with the air mattress along with the resident to the newly assigned room.


  • Palliative care/hospice – assumption of wound development as unavoidable
  • Weight loss not identified on a timely basis– omissions of documentation of ordered weekly/monthly weights, supplements not being accepted
  • Insufficient monitoring of non-pressure related wounds with subsequent deterioration to pressure injury.
  • Untreated pain which interferes with mobility and/or mood with resulting immobility/pressure injury development risk

In Part 3 of the CMSCG “Ftag of the Week” for F686 Treatment/Svcs to Prevent/Heel Pressure Injuries, we will review regulatory expectations for treatment of pressure injuries and some helpful tips for the clinical team. To learn more about CMS Compliance Group, Inc., click here.


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