Delay in Initiation and Documentation of Wound Care Treatment
Penalty
Summary
The facility failed to provide timely wound care according to orders and established procedures for one resident with a left gluteal skin alteration. The resident, who is severely cognitively impaired, non-verbal, and has multiple significant diagnoses including chronic respiratory failure with hypoxia, tracheostomy, dysphagia, encephalopathy, and dependence on supplemental oxygen, was admitted on an unspecified date. On 1/23/26, an unidentified CNA reported to an LPN that the resident had a small superficial skin alteration on the buttocks. The LPN stated she reported this to the wound team but did not document the intervention or the skin issue in the resident’s medical record, acknowledging that if it is not documented, it is considered not done. The Wound Care Coordinator later stated he could not recall being informed of the skin alteration on 1/23/26 and only contacted the physician for a treatment order on 1/27/26. The physician’s order for wound care to the left gluteal area, including cleansing with normal saline, applying zinc oxide paste, and covering with silicone bordered foam every day and as needed, was dated 1/28/26, and the Treatment Administration Record shows the initial wound treatment dated 1/27/26. The DON stated it was her expectation that nurses provide timely nursing interventions to prevent further tissue breakdown and acknowledged that treatment was not started until about three days after the skin alteration was first reported, although she described the wound as very small. The facility’s change in condition policy requires timely communication of medical care problems to the attending physician, and the RN/LPN job description requires timely notification of the medical director. The delay between the initial report of the skin alteration and the initiation and documentation of wound treatment constitutes the deficiency.
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