Bedrock HCS at Greendale: Pressure Injury Neglect WI

GREENDALE, WI - Heritage Square Health Care Center failed to implement adequate incontinence care protocols for a bed-bound resident, leading to the progression of moisture-associated skin damage to a stage 3 pressure injury, according to a state inspection completed March 19.

Critical Care Plan Failures Led to Worsening Pressure Injury

The inspection revealed significant gaps in care planning for a resident who was admitted with existing pressure injuries and moisture-associated skin damage (MASD) to her coccyx area. Despite being identified as "always incontinent of bowel and bladder" and requiring total assistance for toileting, the facility failed to establish a personalized incontinence management protocol.

The resident's care documentation showed she needed repositioning every 2-3 hours and required heel boots at all times, but contained no indication of how often the resident should be checked and changed for incontinence. This omission proved critical, as the resident's condition deteriorated during her stay.

Medical records confirm that what began as MASD progressed to a stage 3 pressure injury over approximately five weeks. A stage 3 pressure injury involves full-thickness skin loss, potentially extending into underlying tissue, and represents a serious wound that can lead to complications including infection, sepsis, and prolonged healing times.

Medical Professional Identified Clear Protocol Gaps

The facility's nurse practitioner recognized the connection between inadequate incontinence care and the resident's worsening condition. When asked about the cause of the MASD, the nurse practitioner stated it was "probably combination of wetness from incontinence and shearing."

"Of course. I'm sure they have a protocol for weight shifting and skin care incontinence protocol," the nurse practitioner told inspectors when asked if routine checking and changing would be expected for a resident with moisture-related skin damage.

The medical provider had documented specific care requirements, noting that "the balance of moisture is critical to wound healing" and recommending a skin care and continence schedule per facility protocol. However, nursing staff failed to translate these medical directives into actionable care plans.

Industry Standards Require Comprehensive Incontinence Management

Proper incontinence care in nursing homes requires systematic approaches that address both the frequency of checks and the methods used to protect skin integrity. Best practices include establishing individualized toileting schedules, using appropriate barrier products, and implementing moisture-wicking strategies.

For residents with existing skin damage, the standard of care becomes even more stringent. Moisture from incontinence creates an environment that breaks down healthy skin and prevents wound healing. When combined with pressure and shearing forces from repositioning, this creates optimal conditions for pressure injury development and progression.

The facility's nurse practitioner had provided specific instructions about managing skin moisture, including using skin barriers and wicking agents, and had documented that the resident wore adult briefs. Despite these clinical recommendations, the nursing staff failed to implement the systematic checking and changing protocols necessary to prevent further skin breakdown.