Failure to Provide Immediate Wound Care Orders for Resident
Summary
The facility failed to ensure that a resident had physician orders for immediate care upon admission, specifically regarding wound care treatment. The resident, a female with multiple medical conditions including acute kidney failure, urinary tract infection, morbid obesity, and stage 3 pressure ulcers, was admitted without appropriate wound care orders. Despite having multiple areas of shearing and pressure ulcers, the facility did not initiate wound care treatment until several days after admission, leading to a delay in care. Upon admission, the resident had several pressure ulcers, including on the right hip, right thigh, and left thigh, which were not addressed with immediate wound care orders. The facility's records indicated that the resident's wounds were not properly assessed or treated in a timely manner, and there was a lack of documentation regarding the initiation of wound care. The facility's staff, including the admitting nurse and other clinical staff, failed to obtain or implement necessary wound care orders, resulting in a lack of appropriate treatment for the resident's pressure ulcers. Interviews with facility staff revealed a lack of communication and understanding of the procedures for obtaining and implementing wound care orders. The admitting nurse did not receive a timely response from the nurse practitioner regarding wound care, and there was confusion among staff about the resident's wound care needs. Additionally, the facility did not provide the resident with a specialty mattress or pressure-relieving devices, further contributing to the inadequate care of the resident's pressure ulcers.
Removal Plan
- Resident #93 had wound care orders written.
- A weekly wound assessment was completed.
- A specialty mattress was placed on Resident #93's bed.
- Resident #93's heels were floated.
- Skin sweep completed to ensure all skin issues were identified and had current orders and interventions in place.
- Director of Clinical Education will educate Director of Clinical Services and Assistant Director of Clinical Services on the process of reviewing new resident admissions electronic health records for completion of order transcription as it relates to wound orders as well as carrying out those orders.
- If a RN or wound care certified LVN is not on duty at the time a resident admits, the admitting nurse on duty will utilize Advanced Wound Care Telehealth for a consult.
- All licensed nurses will be educated by the ADCO or designee on the process of carrying out orders for residents admitted with wounds or obtaining orders if no order accompanies the resident when admitted.
- Education will also include the completion of weekly skin assessments per schedule.
- All licensed nurses will receive in-service regarding wound care orders and weekly skin assessments prior to the beginning of their next shift.
- Any newly hired nurses will receive the above education upon hire during orientation prior to taking a shift on the floor.
- Ad hoc QAPI meeting will be held with the Medical Director reviewing the policies and procedures for wound care.
- All licensed nurses will be educated on the Skin Management policy regarding general guidelines, prevention, notification, treatment, and documentation by the Director of Clinical Education or designee.
- All C.N.A.'s will be educated by the Director of Clinical Education or designee regarding pressure ulcer prevention and interventions for residents with pressure ulcers.
- Director of Clinical Operations or Assistant Director of Clinical Operations will review all orders for new admissions every day in the morning clinical meeting to ensure orders have been written and carried out for residents admitted with wounds.
- Director of Clinical Operations or designee will review weekly skin assessments daily to ensure timely completion.
- Director of Clinical Operations or designee will review wound physician documentation weekly to ensure any orders are carried out timely.
- Director of Clinical Operations and/or designee will review all wound care patients orders, interventions, and skin assessments during Standards of Care Meeting weekly.
- The Administrator, Director of Clinical Operations and/or designee will review the action plan developed related to obtaining wound care orders, implementing wound care interventions, and weekly skin assessments in QAPI meeting monthly during the next six months.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with multiple chronic conditions and an indwelling Foley catheter did not have physician orders in place for the catheter at admission. Medical records, nursing notes, and the care plan lacked documentation of the catheter order, although CNA documentation confirmed care was provided and surveyors observed the catheter in use. The DON confirmed the absence of physician orders, and the facility lacked a related policy.
A resident with critical illness myopathy and moderate cognitive impairment was readmitted from the hospital without physician notification or medication and treatment orders in place. Staff, including an LPN, confirmed they lacked the necessary orders to provide proper care, and both the medical director and nurse practitioner were not informed of the readmission. The DON acknowledged the orders were not transcribed as required.
A resident with a surgical incision was admitted without proper orders for incision care, leading to a delay in treatment. The hospital recommended washing the incision twice daily, but the facility did not initiate this care until several days later. The ADON confirmed the oversight in obtaining necessary orders upon admission.
Lack of Physician Orders for Indwelling Foley Catheter
Penalty
Summary
The facility failed to ensure that physician orders were in place for a resident with an indwelling Foley catheter at the time of admission. The resident, who was admitted with multiple diagnoses including atrial fibrillation, congestive heart failure, liver cirrhosis, diabetes mellitus type 2, and chronic kidney disease with dialysis, was cognitively intact and required significant assistance with activities of daily living. Medical record review showed no physician orders for the Foley catheter, and there was no documentation in the nursing progress notes or plan of care regarding the catheter. Certified Nursing Assistant documentation confirmed care was provided for the catheter, and observations during the survey verified the presence of the indwelling Foley catheter. The Director of Nursing confirmed the absence of physician orders, and the facility did not have a policy related to physician orders for indwelling Foley catheters.
Failure to Notify Physician and Obtain Orders on Resident Readmission
Penalty
Summary
Licensed nursing staff failed to notify the physician of a resident's readmission and did not obtain medication or treatment orders to guide care for the resident upon return from the hospital. The resident, who had a diagnosis of critical illness myopathy and moderate cognitive impairment, was readmitted to the facility, but there was no evidence in the medical record that physician orders for medications or treatments were in place on the date of readmission. Staff interviews confirmed that the LPN working on the unit at the time did not have any orders to properly care for the resident and did not notify the provider of the resident's return. Further interviews revealed that both the medical director and nurse practitioner were not informed of the resident's readmission, and the director of nursing acknowledged that there was no reason for the failure to transcribe or enter the necessary orders. The administrator stated that it was expected for all orders to be entered and the provider notified immediately upon admission or readmission, but this did not occur in this instance.
Failure to Obtain Admission Orders for Surgical Incision Care
Penalty
Summary
The facility failed to ensure that admission orders were obtained for a resident with a surgical incision, which led to a deficiency in providing appropriate care and treatment. Resident #178, who was admitted with a surgical incision on the neck, did not have any orders in place to wash the incision as recommended by the hospital from which they were discharged. The hospital record indicated that the incision should be washed twice daily with soap and water, but this was not initiated until several days after the resident's admission. Upon observation, it was noted that the resident had clear tape covering the incision, and the resident reported that no treatments had been performed on it by the facility. The physician orders for the month did not include any instructions for incision care until an order was finally placed to wash the incision every shift. The Assistant Director of Nursing confirmed that there should have been an order in place upon admission to cleanse the surgical incision, which was not done, resulting in a lapse in care.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
