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F0686
E

Failure to Follow Wound Care Treatment Orders for Pressure Ulcer

Huntingdon, Pennsylvania Survey Completed on 04-10-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to follow wound care treatment recommendations for a resident with a Stage 3 pressure ulcer on the coccyx. According to the facility's wound treatment policy, evidence-based treatments should be provided in accordance with physician orders. The resident, who was cognitively impaired and required assistance with care, had wound consultations that recommended daily application of collagen to the wound bed and zinc to the peri-wound area. However, review of the Treatment Administration Records showed that collagen was not applied daily as ordered from January 15 through February 5. Further, a subsequent wound consultation recommended daily application of bacitracin ointment and collagen to the wound bed, but records indicated that no treatment was applied to the coccyx from February 20 through 26. The DON confirmed that the recommended treatments were not completed as ordered on the specified dates.

See complete original report
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