F0684

E

Failure to Provide, Document, and Order Appropriate Wound Care and NPWT Supplies

Colfax, Washington Survey Completed on 01-28-2026

Penalty

No penalty information released

Summary

The deficiency involves multiple failures to provide ordered wound care, to timely obtain and document wound care supplies, and to enter and clarify wound care orders for residents with non-pressure skin conditions and surgical wounds. One resident was admitted with multiple lower extremity ulcers and scheduled wound care, including Unna boots and compression wraps, later modified to various dressing regimens and oral antibiotics for infected bilateral lower extremity wounds. Medication administration records (MARs) for several months showed numerous entries marked as refused, held, or left blank for ordered dressing changes and one antibiotic dose, with at least one dressing change held without a corresponding provider order or indication that the provider was aware. The resident’s care plan included actual wounds and later an infection of bilateral lower extremity wounds, but contained no focus or interventions addressing the resident’s repeated refusals of wound care or any documented risk–benefit discussion, even though the resident reported concern that dressings were not done regularly and that their legs were starting to smell bad.

Another resident was discharged from the hospital with an open surgical wound on the right lower leg requiring NPWT (wound vac) with specific frequency and settings. The facility care plan noted cellulitis and infection of the right lower extremity but did not address the wound vac order or refusals of wound care. MARs over several months showed repeated NN (other/progress note), blank, held, and refused entries for NPWT dressing changes. Progress notes documented that the resident did not arrive from the hospital with a wound vac and instead had wet-to-dry dressings, that the wound vac canister was found full with the dressing dripping with fluid, and that staff were using wet-to-dry dressings while awaiting wound vac supplies. A third resident with a large abdominal wound and an order for NPWT three times weekly had multiple blank, NA, and refused entries on the MAR, and the Resident Care Manager stated that supplies were running out because staff were not notifying them when supplies were low and that it took about seven days to obtain new supplies.

Additional deficiencies involved failures to enter and clarify wound care orders for surgical wounds. One resident underwent a left below-knee amputation and was admitted with a surgical wound and sutures; the admit assessment documented that the resident removed the dressing due to itching, with some bleeding and redressing by staff, but no wound care focus or interventions were added to the care plan. No wound care orders were entered for this surgical site until 11 days after admission, and the initial order lacked a specified wound site and solution strength, with MAR entries coded NN and progress notes indicating the order was unclear and needed clarification. The order was discontinued, leaving an 11-day gap before a new, more detailed order was entered. Another resident admitted after right hip fracture repair had a surgical wound and required surgical wound care per the admission MDS, but no surgical wound care or monitoring orders appeared on the MARs during their stay, and the Resident Care Manager reported that the resident came from the hospital with unclear instructions and they were not sure if wound care was performed.