F0686

D

Failure to Obtain Wound Treatment Order and Incorrect Pressure-Relieving Mattress Setting

Greensboro, North Carolina Survey Completed on 01-10-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to obtain a physician order for treatment of a documented stage 3 pressure ulcer and failure to correctly set a pressure-relieving air mattress for a resident with multiple pressure ulcers. The resident was admitted with diagnoses including cerebrovascular disease, type 2 diabetes, hypertension, a sacral pressure ulcer, and peripheral vascular disease, and had severe cognitive impairment and dependence in ADLs. The care plan identified a coccyx pressure ulcer and risk for further breakdown, with goals for healing and interventions such as skin assessments and weekly wound documentation. Weekly skin reviews and wound measurements beginning on 12/23/25 showed stage 3 pressure ulcers on the sacrum and left buttock, and later documentation showed an additional stage 3 ulcer on the right buttock.

Physician orders dated 12/24/25 were present for treatment of the sacral and left buttock stage 3 pressure ulcers, specifying cleansing with Dakin’s/normal saline, application of honey fiber, and coverage with a silicone super absorbent pad. However, there was no corresponding treatment order for the right buttock ulcer, despite the wound being identified on 12/23/25 and documented as a stage 3 pressure ulcer with specific measurements on 01/07/26. The Treatment Administration Records for December 2025 and January 2026 showed wound care being provided to the sacral area and left buttock starting 12/23/25, but no documented treatment order for the right buttock ulcer in December. The Wound Care Nurse reported that all three wounds (left buttock, right buttock, and sacrum) were identified on 12/23/25 and that she had been treating all of them, but she had not realized there was no physician order in place for the right buttock.

A separate deficiency was identified regarding the pressure-relieving air mattress settings for the same resident. Observations on consecutive days showed the resident in bed with the air mattress set at 350 lbs, while the medical record documented the resident’s weight as 133.5 lbs. Nursing staff interviews revealed that the nurse assigned to the resident was not aware she was responsible for checking the weight setting on the pressure-relieving mattress. The Wound Care Nurse stated that it was the hall nurse’s responsibility to ensure the mattress weight setting was correct. These observations and interviews demonstrated that the mattress was not set according to the resident’s actual weight and that staff were unclear about their responsibility for verifying and adjusting the mattress settings.