F0684

D

Failure to Assess, Treat, and Document Resident Leg Wounds per Standards and Care Plan

Price, Utah Survey Completed on 01-29-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide treatment and care in accordance with professional standards and the resident’s care plan for skin integrity. A resident with Type 2 diabetes and restless leg syndrome reported having open sores on his lower leg for at least a week and stated he had informed a nurse, who applied bandages, but he continued to bleed through the bandages onto his socks. On observation, the resident’s right lower extremity below the knee was reddish-purple with a large bandage saturated with serosanguineous drainage leaking onto his sock, and two additional draining areas were uncovered. There was no documentation in the medical record of any leg wounds, wound assessments, or wound treatment orders, despite the resident’s report that bandages had been applied previously.

Further observations and interviews showed that the resident’s wounds were not being consistently assessed or documented. During a dressing change, an RN told the resident she needed to ensure his wounds were documented in the computer to be assessed daily, but there was still no wound care order or progress note documenting his skin condition in the record the following day, and the resident reported that no nurse had assessed or changed his bandages that day. The resident’s care plan, initiated months earlier, included a goal for intact skin and interventions such as daily body checks and immediate nurse notification of any new skin breakdown, redness, blisters, bruises, or discoloration, but these interventions were not effectively implemented or documented for this resident’s leg wounds. Interviews with nursing leadership confirmed that required steps such as documenting skin changes, entering wound care orders, and completing appropriate notes were not carried out as expected for this resident.