Failure to Complete Weekly Wound Assessments and Care Planning
Penalty
Summary
The deficiency involves the facility’s failure to provide comprehensive weekly assessment and care planning for a resident’s non-pressure wound in accordance with facility policy and physician orders. The facility’s skin policy dated 11/2022 requires licensed nursing staff to document weekly integumentary findings, including wound appearance, measurements, treatments applied, and evaluation, and to update the plan of care with each intervention. The resident, admitted with a traumatic brain injury and having a guardian, was seen by a wound care physician on 12/4/25 and identified as having a full-thickness non-pressure wound to the right upper scapula measuring 6 cm by 6 cm by 0.1 cm with light serous drainage and 10% necrotic tissue. On 12/11/25, the wound care physician documented that the wound measured 6 cm by 3 cm by 0.1 cm with light serous drainage and 20% slough, which was debrided, and recommended continued treatment with a gauze island border dressing, repositioning per facility protocol, and off-loading of the wound, with weekly follow-up. A subsequent wound care visit on 12/18/25 was rescheduled due to the resident’s refusal of wound evaluation. Despite these findings and orders, the resident’s medical record contained no comprehensive wound assessment after 12/11/25 through 1/6/25, even though the DON stated that the wound care doctor comes weekly and that either the RN manager or floor nurse would conduct wound rounds and assessments. The resident’s plan of care did not identify the non-pressure wound, and therefore contained no documented, person-centered interventions to promote healing or to evaluate whether interventions or treatments needed adjustment. Interviews with the DON and RN/unit manager confirmed that they could not produce any comprehensive wound assessments after 12/11/25 and that the wound had not been added to the care plan, with the RN/unit manager stating that the MDS nurse completes care plans but not knowing why the wound was not included. During an observation on 1/5/26, the surveyor noted two wound areas on the resident’s right upper scapula consistent with the 12/11/25 assessment, further confirming the ongoing presence of the wound without corresponding weekly assessments or care plan documentation.
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