F0684

E

Failure to Assess Change in Condition and Provide Consistent Wound Care for Two Residents

Clearwater, Florida Survey Completed on 01-16-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide appropriate assessment and care in response to changes in condition and to consistently provide and document ordered wound treatments for two residents with complex medical needs. For one resident with COPD, CHF, diabetes, peripheral vascular disease, and a below-knee amputation, the record showed he was cognitively intact, on continuous oxygen, and had PRN orders for ProAir inhaler and albuterol nebulizer for shortness of breath. On the day of his death, the MAR documented administration of ProAir at 11:02 p.m. and an albuterol nebulizer at 11:18 p.m., both marked as ineffective. The progress note by the LPN on duty stated she received report that the resident was not easily waking up, found him restless and congested, administered the inhaler and nebulizer, and called 911; EMS arrived and the resident expired at 11:59 p.m.

Interview with the LPN revealed that she was told by the outgoing nurse that the resident was not doing well and that the outgoing aide and the resident’s roommate reported he had been more sleepy and not eating throughout the day. The LPN stated that when she assessed him, he was wheezing, had a pulse oximetry reading in the 80s, and elevated respirations, but she did not check his blood pressure. She reported that she believed he improved after the treatments and called another LPN to check on him, and that the resident had a pulse and was breathing when EMS arrived. The DON confirmed there was no SBAR, no documented assessment or vital signs after the morning vitals at 8:39 a.m., and no documentation that the resident’s emergency contact was notified of the change in condition. The DON also stated she did not know whether oxygen was applied, did not account for the 40-minute interval between the last PRN treatment and the time of death, and verified that the facility’s change-in-condition policy requires physician and representative notification and documentation of changes in condition.

For a second resident with CHF, heart transplant status, ESRD on dialysis, diabetes, lymphedema, chronic venous hypertension, multiple chronic leg ulcers, and a left buttock pressure ulcer, the facility failed to consistently provide and document ordered wound care and weekly wound assessments. Physician orders directed daily wound care to the left buttock and right lower extremity using Santyl, Manuka honey, calcium alginate, and absorbent dressings, with additional orders after hospitalization for continued daily treatments to the buttock and extensive right lower leg venous ulcers. Review of the TARs for two consecutive months showed multiple days where ordered wound treatments were not documented as performed, with some days marked as out of facility or refused, but several days left blank with no indication of care provided. Weekly wound evaluations were incomplete or missing for multiple dates, and some wound evaluation entries for different dates were documented as written on the same later date.

Additional documentation showed that the resident had large, full-thickness venous ulcers on the right lower leg, including lateral and medial anterior areas, with extensive necrotic tissue, copious drainage, and exposed necrotic adipose, and a left buttock Stage III pressure ulcer. A wound NP note described extensive ulcers covering approximately 60% of the right leg with large areas of necrotic tissue and recommended IV antibiotics and hospital transfer for surgical debridement, while continuing Santyl and calcium alginate. The care plans required weekly skin checks, measurement and documentation of wound size and status, monitoring for signs of infection, and notifying the physician and resident/representative of changes. The DON confirmed that wounds were to be evaluated at least weekly, that only limited wound evaluations were present in the e-chart, that the wound care nurse should have been documenting weekly follow-up, and that the discharge summary listed multiple open vascular wounds on both lower extremities and a buttock wound, without addressing the gaps in wound care and assessment documentation identified in the TARs and wound records.

The facility’s own policies on prevention of skin impairment and change in resident condition required comprehensive skin assessments on admission, ongoing inspection during care, evaluation and documentation of changes in skin condition, and timely notification of the physician and resident representative of changes in condition. For both residents, the documentation and interviews showed that these processes were not followed: for the first resident, there was no documented comprehensive assessment, vital signs, SBAR, or representative notification in response to a significant change in respiratory status prior to death; for the second resident, there were repeated lapses in performing and documenting ordered daily wound treatments and weekly wound evaluations for extensive vascular and pressure wounds, despite care plan directives to monitor, measure, and document wound status and to notify the physician of changes.