F0686

D

Failure to Implement Wound Care Recommendations and Prevent Worsening Pressure Injuries

Tacoma, Washington Survey Completed on 01-12-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide adequate pressure injury (PI) prevention and treatment for a dependent resident with multiple existing wounds and high risk for skin breakdown. On admission, the resident had bilateral heel wounds and wounds to the right lower extremity and required substantial/maximal assistance for bed mobility and was totally dependent on staff for turning and repositioning. The MDS documented the resident was not on a turning/repositioning program, and the care plan, while noting bilateral heel pressure ulcers and wounds to the right lower extremity with a goal for healing, did not include a turning schedule or pressure-relieving mattress. Staff interviews confirmed the resident could not turn without assistance, that CNAs relied on the Kardex for care instructions, and that there was no order or care plan for a pressure-relief mattress.

The facility used a contracted wound care and treatment company (WCTC) to manage the resident’s PIs. WCTC progress notes documented a right heel/foot Stage 4 PI that initially measured 15.75 cm² pre-debridement and 19.11 cm² post-debridement, with 100% necrotic tissue. Subsequent weekly assessments showed fluctuating but generally worsening wound characteristics, including increasing necrotic tissue, maceration, erythema, and a significant increase in wound size to 48 cm². WCTC notes over several visits identified peri-wound maceration and erythema and recommended multiple PI-related interventions, including aggressive offloading. However, review of the resident’s EHR, orders, care plans, and Kardex showed no documentation that any of the ten WCTC-recommended interventions were implemented. The resident completed an initial course of antibiotics shortly after admission, and no further antibiotics were ordered prior to hospital transfer, despite ongoing wound issues and later-confirmed osteomyelitis.

Additional wounds were not identified or documented by facility staff prior to the resident’s transfer to the hospital. WCTC documentation showed a left 4th toe wound first described as a non-pressure chronic ulcer with 100% necrotic tissue and fragile peri-wound skin with mild erythema and maceration, later reclassified as an unstageable PI with persistent 100% necrotic tissue and progression to severe erythema and severe maceration. The facility’s EHR contained no documentation that this left 4th toe PI was present on admission or that it was identified or treated by the facility before transfer. Hospital records documented, at the time of admission, an unstageable right heel PI, a deep tissue PI to the left lateral ankle, and an unstageable sacral PI, all present on admission, yet the facility’s EHR contained no documentation that the left lateral ankle PI or sacral PI had been identified or treated. Hospital podiatry and provider notes later confirmed right calcaneal osteomyelitis with a non-salvageable right lower extremity and concern for osteomyelitis in the left calcaneus. Facility nursing and management staff acknowledged that WCTC recommendations had not been entered as orders or care-planned and that direct care staff relied on the Kardex, which did not reflect these interventions.

Provider follow-up notes from the facility documented the resident’s reports of stabbing pain in both feet, heels, and sometimes up to the knees, and a decrease in effectiveness of gabapentin, with discussion of increasing the dose. These notes did not include any documented physical examination of the resident’s feet or foot wounds. A nurse’s progress note later recorded the resident’s transfer to the hospital for a non-pressure injury/pain-related care need. At the hospital, wound nurse and podiatry consults documented multiple PIs, including those not previously documented by the facility, and confirmed severe infection and osteomyelitis. Throughout this period, the facility’s failure to implement WCTC recommendations, to provide documented offloading and pressure-relief measures, to identify and document new or worsening PIs (left 4th toe, left lateral ankle, sacral area), and to conduct and document appropriate wound assessments and follow-up contributed to the identified deficiency in providing pressure ulcer care and preventing new ulcers from developing.