F0686

D

Failure to Coordinate Wound Care, Wound Vac Use, and Nutrition for Resident With Multiple Pressure Ulcers

Raleigh, North Carolina Survey Completed on 01-08-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide appropriate pressure ulcer care and to prevent the development and worsening of multiple pressure sores for a resident with significant medical comorbidities and recent spinal surgery. The resident was admitted after a complicated hospitalization that included spinal decompression surgery, epidural hematoma, sepsis, and multiple chronic conditions such as COPD, diabetes, hypertension, obesity, neuropathy, and a history of alcoholism and drug use. On admission, the resident was identified as at risk for pressure sores and for weight loss/malnutrition, with an albumin of 3.5 and an admission weight of 226 pounds, down from 240 pounds at hospital discharge. Early documentation by the facility Wound Nurse misidentified the anatomical site of moisture-associated skin damage (MASD) and an open area, charting it as the right buttock when it was actually on the left, and subsequent orders and NP documentation continued to reference incorrect or inconsistent anatomical locations.

As the stay progressed, the resident developed multiple pressure sores to the buttocks, sacrum/coccyx, and gluteal folds. There were repeated inconsistencies and gaps between wound assessments and the entry of corresponding treatment orders. On 11/3, a Stage II buttock pressure sore was documented and treated with collagen and a border gauze, but the site was again mis-labeled as the right buttock when the Wound Nurse later stated it was on the left. On 11/10, the Wound Nurse documented four pressure sore sites, including non‑stageable areas and a Stage II right buttock wound, but no new treatment orders were entered that day, and the November TAR showed only collagen treatment to the right buttock on 11/10 and 11/11. The Wound Nurse stated she would have used facility wound protocols on 11/10 and 11/11 but did not document this, and acknowledged that without orders, other nurses would not know the treatment plan. On 11/12, the Wound Nurse documented necrotic tissue, foul odor, and multiple pressure areas, while the Wound NP’s note the same day described several new unstageable wounds but did not mention the coccyx/sacrum wound or foul odor, and wound numbering and locations were inconsistent with prior documentation.

The facility also failed to timely and consistently address the resident’s nutritional status and significant weight loss in relation to wound development and healing. The RD first recommended Med Plus 1.7 on 10/31 due to intake not consistently meeting estimated needs, but no physician order for this supplement was entered in October or November. The resident experienced a substantial weight loss from 226 pounds on admission to 197.2 pounds by mid‑November, with a drop in albumin from 3.5 to 3.0, and one weekly weight was missed. The RD did not document further follow‑up until 12/8, at which time a more than 30‑pound weight loss over two months and three pressure sores were noted, and supplements including Med Plus, multivitamin, vitamin C, and zinc were again recommended; these were not started until 12/10.

After hospitalization for a worsening left‑sided sacral/buttock ulcer requiring sharp debridement and initiation of negative pressure wound therapy (wound vac), the resident returned to the facility on 12/5 with orders to resume wound vac therapy as soon as possible and to use a low air loss bed, strict turning, and activity restrictions. No pressure sore treatment orders were entered into the electronic record until 12/8, and there were no documented wound treatments on 12/6 and 12/7. A nurse who cared for the resident that weekend reported not knowing where to obtain a wound vac and believing it had to be specifically ordered, so she applied wet‑to‑dry dressings instead. The DON stated a wound vac was available in the treatment room and that multiple nurses were trained to apply it, and she had not been notified that staff could not locate or use it. When the Wound Nurse returned on 12/8, she found no wound orders in the system and no wound vac in place, only a clean wet‑to‑dry dressing, and then initiated wound vac and dressing orders. Throughout the stay, the care plan and documentation were updated intermittently, but the report describes failures in accurate wound site identification, timely order entry, consistent implementation of wound vac therapy, and systematic evaluation of the resident’s nutritional decline in relation to the development and worsening of multiple pressure sores.