F0656

D

Failure to Integrate Wound Specialist PI Interventions Into Resident Care Plan

Tacoma, Washington Survey Completed on 01-12-2026

Penalty

No penalty information released

Summary

Facility staff failed to develop and implement an individualized comprehensive care plan incorporating wound care specialist recommendations for a resident at risk for pressure injuries (PIs). The facility’s Skin Integrity Management policy, dated 05/26/2025, directed staff to develop comprehensive, interdisciplinary plans of care for prevention and wound treatments, including offloading devices, turning and repositioning, special wound care techniques, and appropriate support surfaces, and to review and revise care plans as indicated. The resident was admitted with diagnoses including diabetes, malnutrition, and muscle weakness, was identified on the admission MDS as being at risk for PIs, admitted with existing PIs, and totally dependent on staff for turning and repositioning in bed.

A wound care specialist documented progress notes on 10/08/2025 listing nine specific recommended interventions and preventive measures related to the resident’s PIs, including turning every two hours, keeping skin clean and dry, avoiding massage of bony prominences, using positioning devices, keeping the head of bed as low as possible to reduce shearing, keeping sheets dry and wrinkle-free, and removing all fragranced products in favor of chemical-free, fragrance-free disposable washcloths. On 10/22/2025, the wound care specialist added a tenth recommendation for aggressive offloading. Review of the resident’s care plans and Kardex on 11/19/2025 showed that none of these ten recommendations had been added to the care plan or Kardex. On 12/17/2025, the DON confirmed that there were no provider orders for the recommended interventions, none of the ten recommendations were care planned or present on the Kardex, and stated that CNAs rely on the Kardex and verbal shift report to know resident care needs.