F0686

E

Failure to Implement Wound Care Orders and Off‑Loading Interventions for Pressure Injuries

Saint Louis, Missouri Survey Completed on 01-08-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure accurate transcription and implementation of wound care provider orders, timely initiation of new pressure injury treatments, and inclusion of a resident’s pressure injury in the care plan. For one quadriplegic resident with impaired cognition and total dependence for mobility and ADLs, a pressure injury to the sacral/right buttock area was identified in early November. The wound care company physician ordered a change in dressing from calcium alginate to calcium alginate with silver on 11/13, but the facility’s Treatment Nurse did not update the physician order sheet (POS) or treatment administration record (TAR). As a result, the TAR continued to list calcium alginate only through January, and staff nurses reported they would follow what was written on the TAR, meaning they may not have used the ordered calcium alginate with silver. The resident’s care plan also did not identify the presence of a current pressure injury despite documentation of a recurrent coccyx/right buttock wound and ongoing wound care.

For the same resident, the wound care physician ordered amoxicillin‑clavulanate for the pressure injury on 1/2, but the POS and MAR instead showed Bactrim DS being administered twice daily starting 1/3, with no documentation explaining the change from the wound care physician’s written order. The DON later reported a verbal confirmation from the wound care physician that Bactrim DS was desired, but this clarification occurred after the period in which the MAR showed Bactrim being given in place of the originally ordered amoxicillin‑clavulanate. Throughout this time, the wound care physician’s subsequent notes continued to list amoxicillin‑clavulanate as the recommended antibiotic, while the facility records reflected Bactrim DS administration.

The facility also failed to timely implement new wound care orders for two other residents and to ensure ordered off‑loading devices were in place. One resident with cerebral palsy, severe cognitive impairment, total dependence for mobility, and bowel and bladder incontinence had existing orders for skin prep to the left dorsal foot and left heel and for off‑loading boots to be worn at all times. On 1/2, the wound care physician documented new Stage 3 pressure injuries on the left dorsal foot and left heel and ordered calcium alginate with silver dressings once daily, along with continued use of pressure off‑loading boots. However, the POS and TAR were not updated to reflect the calcium alginate with silver until 1/5, and staff continued to document application of skin prep on 1/2–1/4. During observation on 1/5, the resident’s left dorsal foot and heel had open pressure injuries with dressings dated 1/2, and on 1/7 the resident was observed in bed without off‑loading boots; CNAs reported the boots had been sent to laundry and not yet returned, despite an order for boots to be on at all times.

Another resident with a history of wound infection, diabetes, stroke, severe cognitive impairment, and total dependence for mobility had an order for zinc oxide ointment to the right buttock. On 1/2, the wound care physician documented a Stage 3 pressure injury on the right posterior thigh and ordered calcium alginate with silver once daily. The facility did not enter this new order on the POS and TAR until 1/5, and nurses continued to initial zinc oxide application on 1/2–1/4. On 1/5, observation showed open horizontal areas on the right posterior thigh without a dressing in place, and the Treatment Nurse acknowledged she had been on vacation when the wound care physician rounded and that the new order from 1/2 had not been added until her return. Across these cases, the facility’s own policies requiring prompt assessment, timely implementation of provider orders, and care plan updates for pressure injuries were not followed.