F0684

G

Failure to Provide Individualized Wound Care, Honor NPO Status, and Manage Chest Drain as Ordered

Columbus, Ohio Survey Completed on 01-15-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide individualized skin care and timely wound identification and treatment for a resident with significant risk factors, including diabetes, peripheral neuropathy, prior diabetic foot ulcers, and a history of toe amputation. Hospital records prior to admission documented multiple foot and heel wounds, including deep tissue injuries and an unstageable pressure injury, with treatments in place and orders for a low air loss surface and bed extender due to the resident’s height and foot contact with the bed frame. Despite this, on admission and during multiple subsequent skin checks, nursing staff documented no skin issues on the resident’s feet and heels, and no specific wound treatment orders were obtained until more than two weeks after admission. Staff conducting skin assessments either did not examine the feet or did not complete follow-up assessments when the resident initially refused, and the wound nurse and wound nurse practitioner were not notified or involved until wounds were identified much later. When the wounds were finally assessed, four diabetic foot ulcers were documented as in-house acquired, and the resident reported that his bed was not initially extended, causing discomfort and contributing to pressure on his feet.

The deficiency also includes the facility’s failure to follow NPO status and properly manage enteral feeding and medication administration for a resident with an esophageal perforation, neck and mediastinal abscesses, and a newly placed gastrostomy tube. Hospital discharge information indicated medications were to be given orally, but the admitting nurse received a verbal report that all medications and feedings should be given via the gastrostomy tube. On admission, the physician order specified NPO, yet multiple medications were transcribed and administered as oral medications on the MAR before orders were later changed to gastrostomy tube administration. There were no initial orders for gastrostomy tube care, enteral feeding, water flushes, or neck incision care, and there was no documentation of enteral feeding administration for the first two days. Later, the resident was found with open food and drink containers at the bedside and had an episode of vomiting; a nurse reported that a new CNA, unaware of the NPO status, delivered a room tray, and that the resident experienced a choking episode and complications from feeding, but this incident was not documented in the medical record after a supervisor instructed the nurse not to document it. The resident’s emergency contact reported seeing the resident consume a beverage at the bedside, followed by nausea, vomiting, and increased green drainage from the neck wound, and the resident was subsequently sent to the hospital, where imaging showed a neck abscess with a sinus tract extending to the skin surface and a probable open wound.

Additionally, the deficiency encompasses the facility’s failure to provide timely and appropriate management of a PleurX chest drain for a resident with malignant pleural effusion and chronic respiratory failure. Hospital discharge instructions specified that the PleurX drain should be drained three times per week, up to 1,000 ml each time, with a drainage log maintained and physician notification if drainage was 200 ml or less for three consecutive days. After readmission, documentation noted the presence of the PleurX drain and a physician order to monitor the site and change the dressing, and the medical director noted the need to monitor for complications such as dislodgement, obstruction, or infection. However, there were no physician orders to drain the PleurX and no evidence of drainage being performed for approximately nine days after readmission. When orders were finally entered, the drain was successfully used, and the ADON later confirmed that the drain had been functional the entire time but was not drained because she did not understand that a protective sheath over the tube should be removed to connect the drainage kit. Attempts to drain the PleurX prior to that date were not documented, and the drain was not managed according to the hospital discharge instructions.