F0684

D

Failure to Complete and Accurately Document Ordered Wound Care Treatment

Marion, Iowa Survey Completed on 01-28-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to complete ordered wound treatment for a resident with a documented Stage III pressure ulcer on the left lateral foot. The resident’s MDS showed diagnoses including heart failure, diabetes, non-Alzheimer’s dementia, vascular disease, and a Stage III pressure ulcer, with severe cognitive impairment (BIMS score 5/15) and a need for staff assistance with ADLs. The care plan directed staff to assess the pressure ulcer and surrounding skin weekly and to complete treatments as ordered. A physician order dated 11/17/25 specified that staff were to cleanse the foot wound and surrounding skin, paint the callous and wound with betadine, cover with a foam dressing, and secure with gauze wrap and tape, to be completed daily on the evening shift.

On 12/16/25, the resident attended a local wound provider appointment and returned without new orders. A progress note from the wound provider on that date documented that the wound appeared worse, with increased dimensions, and described the diabetic left lateral wound as clean, painful, and fragile, present for more than a year. On 12/18/25, a physical therapy treatment note documented that the resident stated wound care had not been completed the previous night and that the wound cover was still dated 12/16 from the wound doctor appointment; the Administrator was notified. An incident report from the same date recorded that the Administrator was informed that the dressing on the resident’s left foot had a past date and had not been changed on the evening shift, and that when the day nurse went to change the dressing, the resident reported that no one had changed the dressing for a couple of days.

Review of the December 2025 treatment record showed that an LPN (Staff K) had signed off the wound treatment as completed on 12/15, 12/16, and 12/17, placing his initials with a check mark indicating completion. In a subsequent interview, Staff K admitted he forgot to do the dressing change on the day the resident went to the wound clinic, could not recall the exact date, and stated he had just signed it off because the wound clinic had done the dressing change that day. He further stated that he did not make any progress notes regarding the wound and reported that everyone else did it that way on days a resident went to the wound clinic. The DON and ADON reported becoming aware of the issue when the resident was found on 12/18/25 with a dressing dated 12/16/25, and an RN confirmed observing the dressing dated 12/16 and completing the scheduled dressing change on her shift because it had apparently not been done as ordered on 12/17. The facility’s medication administration policy required staff to administer medications as prescribed and to sign the medication administration record after administration, underscoring that documentation should reflect actual completion of ordered treatments.