F0684

E

Missed Daily Wound Treatments for Surgical Sacral Wound

San Antonio, Texas Survey Completed on 01-17-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide wound treatment and care according to physician orders and professional standards for one resident with a sacral surgical wound. The resident, an older female with a primary admission diagnosis of aftercare for a surgical tailbone wound and comorbidities including Type 2 diabetes, severe protein-calorie malnutrition, hypotension, hypertension, and a history of substance use, was admitted and later discharged to the hospital for seizure-like symptoms. Her quarterly MDS showed moderate cognitive impairment (BIMS 11), incontinence of bowel and bladder requiring substantial to maximal assistance, and dependence on a wheelchair with substantial to maximal assistance for transfers and mobility. The care plan included interventions for an altered sacral and lower back skin condition, such as an air loss mattress, barrier precautions, weekly skin inspections, and participation in an IV infusion program to promote healing and reduce infection risk.

Serial wound assessments documented a sacral surgical wound that initially measured 4.0 cm x 3.5 cm x 3.0 cm and then showed progressive improvement and stabilization over multiple subsequent measurements, with the most recent measurements indicating a smaller but still present wound. Physician orders directed that the sacral surgical incision be cleansed with normal saline or wound cleanser, patted dry, packed with Iodoform strip, and covered with a dry dressing daily and as needed for soilage or removal, with wound management to occur every day shift. However, review of the Treatment Administration Record (TAR) showed that ordered wound care was not done on three separate days in one month and on one day in the following month. An email from a family member to the surveyor included photographs showing the same bandage in place over multiple days, suggesting that dressing changes had not occurred as ordered.

During interviews, the wound nurse (LVN) acknowledged that wound care was not documented on the identified dates and stated she had been working on the floors as a nurse on those days, expecting an unidentified back-up nurse to perform the wound care; she could not recall who the back-up nurse was and confirmed that wound care was not done on at least one of the missed days. The NP reported that the wound had improved and stabilized over time, with no signs of infection or fecal or urinary contamination, and stated that nurses needed to follow MD orders and that there was no excuse for missed wound care. The DON stated that the resident received incontinence care at least every shift, that weekly skin assessments showed no breakdown or infection from incontinence, and that the resident was sent to the ER for seizure-like symptoms rather than wound issues, only becoming aware of the missed wound care days when informed by the surveyor. The resident’s representative alleged that the resident did not receive proper incontinence care and wound care, reporting feces and urine around the surgical wound and providing photos of what they believed to be a worsening wound. Facility policies on wound treatment management and pressure injury prevention required that wound treatment be provided in accordance with physician orders, but the documented missed treatments showed that this standard was not met for this resident.