F0686

E

Failure to Prevent and Manage Pressure Ulcers and Address Refusals of Wound Care

Colfax, Washington Survey Completed on 01-28-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide appropriate pressure ulcer prevention and treatment for three residents. For one resident, preadmission hospital notes documented a right heel pressure injury, but the facility’s admission skin assessment recorded no issues with the feet, and the admission MDS indicated no pressure ulcers, only risk for development. Despite a care plan dated the same day as admission identifying actual unstageable bilateral heel pressure injuries and directing staff to assess, measure, and monitor the wounds and to offload the heels in bed, there was no documented monitoring or wound care for the heels until mid-December. Skin checks were not documented, and wound assessments for the bilateral heels were not entered into the record until late December, at which time the heels were described as unstageable with blistered, discolored wound bases. Nursing leadership acknowledged being informed of the heel pressure injuries only shortly before the resident left the facility and could not explain the lack of skin checks, monitoring, or wound care orders prior to that time.

For a second resident with multiple pressure injuries on admission, the facility failed to consistently provide ordered wound care and did not address ongoing refusals of care. The admission MDS showed two Stage 3 pressure ulcers and two unstageable DTI wounds with pressure injury care being performed. A skin assessment documented four pressure injuries to both scapulae, the left gluteus, and the left lateral calf, and a later wound assessment showed all four wounds had significantly increased in size. Review of MARs over three consecutive months showed numerous blank boxes where daily or scheduled dressing changes were ordered, along with multiple documented refusals. The care plan identified the actual pressure ulcers and DTIs but contained no interventions for how to address the resident’s frequent refusals of wound care. The medical record did not contain any documented risk-versus-benefit discussions regarding the likelihood of wound worsening related to refusal of care. Nursing staff confirmed that the resident frequently refused wound care, that they did not monitor the MAR to ensure wound care was consistently provided, and that blank MAR boxes indicated wound care was not performed.

For a third resident admitted with a left hip Stage 3 pressure injury, the facility did not enter wound care orders in a timely manner and did not complete a wound culture as initially ordered. The admission skin assessment documented a left hip pressure injury with specific measurements and depth, and the MDS indicated the resident had one Stage 3 pressure ulcer and was receiving pressure ulcer wound care. However, the MAR showed that an order for wound care to the left hip wound, which was present on admission, was not entered until eight days after admission. Later, an order for a left hip wound culture to be completed over a specified multi-day period was entered, but only one MAR box was signed to indicate the resident was out of the facility, and the remaining boxes were left blank, indicating the culture was not obtained as ordered. A second wound culture order was then entered several days later, and the culture was finally collected and resulted, showing mixed bacteria and leading to antibiotic treatment. Nursing leadership stated that clear wound care instructions were not present on the hospital discharge orders and acknowledged that wound care orders were delayed and that the original wound culture order was not completed, causing a delay in results.