F0684

D

Failure to Perform Daily Ordered Wound Dressing Changes

Boulder, Colorado Survey Completed on 10-02-2025

Penalty

No penalty information released

Summary

The facility failed to provide wound care treatment in accordance with physician orders and the resident’s person-centered care plan by not changing a venous leg ulcer dressing daily as prescribed. The resident, under 65 years old, had multiple diagnoses including vascular dementia, type 2 diabetes, diabetic neuropathy, atrial fibrillation, and hemiplegia following a stroke, and was cognitively intact with a BIMS score of 15. The resident required substantial to maximal assistance with toileting hygiene, dressing, transfers, and showering. A physician’s order dated 9/18/25 directed that the venous wound on the left shin be cleansed with wound cleanser, patted dry, treated with calcium alginate and an ABD pad, and wrapped with kerlix gauze every day shift.

On interview, the resident reported that nursing staff were not changing the wound dressing and pointed to the dressing on the left calf. Observation on 10/1/25 showed the left calf wrapped in kerlix gauze with tape dated 9/28/25 and marked with a smiley face, indicating the dressing had not been changed for three days. During a wound care observation later that day, the ADON and an LPN removed the old dressing, revealing a calf wound with a generally red appearance, some beefy red open areas approximately quarter-sized with well-defined borders, and several quarter-sized scabbed areas. The LPN stated the wound was overall healing and then performed wound care per the existing order. The wound care physician confirmed the order for daily dressing changes and stated she expected nursing staff to change the dressing daily when she or the wound care nurse were not present. The DON stated she did not know why the dressing had not been changed as scheduled and acknowledged that nursing staff should follow the physician’s wound care orders.