F0684

E

Failure to Implement and Document Ordered Wound, Skin, and Compression Treatments

Dublin, Ohio Survey Completed on 01-26-2026

Penalty

No penalty information released

Summary

The deficiency involves multiple failures by facility staff to provide and document treatments and care as ordered for several residents. One resident with acute and chronic respiratory failure and morbid obesity had an order for Nystatin powder to the right neck fold twice daily and as needed, along with barrier cream after incontinence. The treatment administration records showed that, aside from a brief period in September, the Nystatin was not documented as given from September through mid-January, and bathing documentation was inconsistent, with several dates showing no bed bath or topical application. Observation revealed raw, red, painful skin under the neck fold, and both an LPN and a CNA acknowledged noticing redness for weeks without consistent treatment or reporting, while the DON confirmed the resident had not received proper topical treatment.

Another resident with osteomyelitis, DM with foot ulcer, toe amputation, cellulitis, lymphedema, and edema had multiple wound and compression orders for a right great toe amputation site and lower extremity compression. The MAR/TAR showed numerous missed daily wound treatments, and there were no wound measurements or status updates to indicate improvement or decline, despite an earlier note stating the wound was closed while orders remained active. After visit summaries (AVS) from wound clinic and hospital visits contained detailed instructions for daily dressing changes and specific compression techniques that frequently did not match the facility’s physician orders, and several AVS documents were missing entirely. The wound nurse and other staff could not verify that treatments were completed, could not confirm certain absences from the facility, and acknowledged that AVS instructions were not consistently transcribed into orders or reflected on the TAR, while observations showed the resident without ordered ace wraps on multiple occasions.

A resident with multiple sclerosis, chronic pain, and generalized weakness had active orders for three topical agents (zinc oxide, triamcinolone, terbinafine) to treat bilateral buttocks MASD three times daily, with cleansing prior to application. The MAR/TAR documented repeated missed administrations across many days in December and January for all three medications, despite progress notes confirming ongoing MASD and care planning for moisture control and incontinence management. The resident reported that staff were supposed to apply cream when she was changed but that treatments were not being completed as ordered, and the DON confirmed there was no documentation explaining the missed treatments and no interventions to ensure compliance with the orders.

Another resident with COPD, DM, and peripheral vascular disease developed a new diabetic ulcer on the left foot, documented in a progress note with detailed measurements and cleansing and dressing instructions. However, the corresponding physician order was not entered until several days later, and the treatment was not documented as completed until the day after the order was written, resulting in a delay between identification of the wound and initiation of ordered care. A separate resident with acute kidney failure, malnutrition, COPD, AFib, and weight loss had an order for bilateral knee-high TED hose once daily for swelling, to be applied on day shift, but repeated observations over several days showed the resident without TED hose, and an LPN confirmed they were not in place as ordered.

A resident with diabetes, morbid obesity, COPD, chronic respiratory failure, and psychiatric diagnoses had orders for wound care to the right groin and left genital region, including cleansing, mupirocin application, packing, and ABD pad coverage twice daily. Review of the TAR for December and January showed numerous dates and times where these treatments were not documented as completed, and an RN verified the missing treatment documentation for the groin wound. Another hospice resident with multiple comorbidities, including obesity, GERD, HTN, OSA, hyperlipidemia, gout, DM, and malignancy of the neck, had a left great toe area first identified by hospice as a DTI. The hospice nurse practitioner recommended preventative betadine treatment and leaving the area open to air starting on the date of assessment, but the facility did not initiate this order at that time. Progress notes were confusing regarding whether the toe had been assessed, no treatments were in place for the toe until a later order, and skin assessments for multiple weeks were created and locked on a single later date, rather than contemporaneously.

A further resident admitted with lumbago with sciatica, COVID-19, acute respiratory failure, bradycardia, hyperlipidemia, and emphysema had a hospital discharge order for an incision to be left open to air with the surrounding skin washed daily with mild soap and water and patted dry. The admission assessment documented a mid-back incision measuring 16 cm by 1 cm, but the MAR/TAR contained no evidence that the daily washing and drying of the skin around the incision was performed. The DON confirmed that this order should have been on the treatment administration record and completed as ordered. Across these residents, surveyors identified failures to complete ordered treatments, failures to transcribe and implement AVS and physician orders in a timely manner, inconsistent or missing documentation of wound and skin care, and lack of alignment between external provider instructions and in-house orders and records.