F0686

K

Failure to Follow Wound Care Orders and Monitor Pressure Ulcers Resulting in Worsening Wounds

Los Alamos, New Mexico Survey Completed on 12-19-2025

Penalty

Fine: $47,075

Summary

The deficiency involves the facility’s failure to provide necessary treatment and services to prevent the development and worsening of pressure ulcers for two residents with wounds. One resident was admitted with a stage 2 coccyx pressure ulcer measuring 2.3 x 4.2 cm and had multiple risk factors, including type 2 diabetes mellitus, an unstageable pressure ulcer diagnosis, muscle wasting and atrophy, and severe protein-calorie malnutrition. The admission evaluation documented a sacral pressure sore and functional limitations requiring assistance with mobility and ADLs. The care plan identified a pressure ulcer and risk for further breakdown but did not include interventions such as a pressure-relieving mattress, wheelchair cushion, or specific repositioning requirements. Weekly wound reports for this resident showed inconsistent documentation, with missing weekly assessments and progression from deep tissue injury to unstageable status, along with changes in wound size and tissue characteristics.

Physician orders for this resident’s coccyx wound changed over time, including orders for collagen dressings, calcium alginate, moisture barrier cream, and later Medihoney with calcium alginate, but the Treatment Administration Records showed missed wound care on multiple ordered days. Moisture barrier cream ordered every shift was only documented twice daily. Staff interviews revealed that a previous wound treatment nurse had been providing wound care treatments without provider orders and that on one occasion a nurse applied a dressing that was not in accordance with the physician’s order, changing to a dressing intended to be changed every three days. A corrective action memo documented that during wound rounds, the dressing found on the resident was not the ordered dressing, bore the initials and date of the nurse who changed it, and the wound was observed to have worsened. The family reported that the wound, initially the size of a quarter on admission, became larger, with blue discoloration around the sore and eventually the size of a business card, and that they were told the dressing orders had been changed so it would be changed less often to reduce pain.

Further documentation for this resident showed that the NP expected orders to be followed and to be notified of wound changes but confirmed she had not been informed of the worsening wound. A nursing note recorded that the resident was discharged to the hospital due to the unstageable wound, and the hospital admission assessment described a large sacral decubitus ulcer, stage III or IV, and noted worsening from the previously documented stage II, quarter-sized wound at the prior hospital discharge. For the second resident, the care plan identified a pressure ulcer or risk related to a history of ulcers but contained no updated wound or treatment interventions. Progress notes documented coccyx redness and later a stage 3 coccyx pressure ulcer measuring 1 x 1 x 0.1 cm. Provider orders directed daily dressing changes with collagen and dry dressing, but the TAR showed wound care documented on only some days, and an observation of wound care revealed a dressing dated six days earlier, indicating that daily wound care had not been performed as ordered. The DON confirmed the dressing age and stated that the TAR entries for several days represented false documentation. The medical director stated he had not been notified that the wound was not improving and that he expected nursing staff, including the wound care nurse, to keep him informed of changes so he could monitor and direct wound care.

The surveyors determined that these failures—missing and inconsistent wound assessments, failure to follow physician wound care orders, provision of wound treatments without orders, lack of appropriate care plan interventions, missed treatments, and inaccurate documentation—resulted in the worsening of pressure wounds for both residents. The facility was notified of a finding of Immediate Jeopardy related to these practices.

Removal Plan

• Assess and treat Resident #4 wound; ensure wound is improving.
• Notify the physician of inaccurate documentation.
• Suspend the charge nurse alleged to have falsified documentation pending investigation.
• Complete an audit of all residents with wounds to ensure all orders are carried out correctly; verify dressings are dated correctly and ordered treatments are in place.
• Re-educate all licensed nurses on the wound care policy.
• Re-educate all licensed nurses on identification of wound progression, including proper wound assessment and monitoring techniques to recognize signs of wound decline or lack of progression.
• Re-educate all licensed nurses on correct documentation of completed wound care.
• Re-educate all licensed nurses on when and how to notify the provider regarding worsening wound status to ensure new orders are obtained as needed.
• Re-educate all licensed nurses on completing wound treatments exactly as ordered.
• Re-educate all licensed nurses on the zero-tolerance policy for falsifying documentation.
• Require nurses to complete competency related to completing wound dressings correctly.
• Complete nurse re-education and competency observation by the interim DON or designee prior to nurses completing any wound care for residents.
• Educate agency nurses prior to their shift beginning by the interim DON or designee.
• Consult with the wound provider for consenting residents.
• Conduct weekly wound audits of current residents with wounds for two weeks, including wound assessment, documentation, notifications, and treatments.
• After the initial two weeks, select 5 random residents weekly for review.