F0684

G

Failure to Follow Wound Care Orders for Diabetic Heel Ulcer Skin Graft

Sheboygan, Wisconsin Survey Completed on 01-20-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure that wound care was provided in accordance with a physician’s orders for a resident with a diabetic heel ulcer being treated with Apligraf skin grafts. The resident had multiple comorbidities including diabetes with polyneuropathy, peripheral artery disease, a prior right below‑knee amputation, and a chronic left posterior ankle/heel diabetic ulcer with visible tendon. Podiatry applied an Apligraf graft to the left heel on 11/3/25 with clear instructions that the graft and underlying dressings (Adaptic and Steri‑Strips) were not to be disturbed until the resident’s follow‑up the next week. A progress note by an LPN on 11/3/25 documented “Wound graft #2 placed on left foot. DO NOT REMOVE.” However, this order was not entered into the Treatment Administration Record (TAR) on the day of the visit.

Subsequent wound care orders in the TAR showed overlapping and changing instructions, including orders to cleanse the wound and apply Hydrofera blue and orders specifying not to remove the skin graft or inner dressings. There were also TAR entries stating “DO NOT REMOVE DRESSING AT LEFT ANKLE UNTIL SEEN AT WOUND CLINIC. NEW GRAFT PLACED” with every‑shift frequency. Staff interviews revealed confusion about the wound care orders, with staff recalling standing instructions to change only the outer dressing and not to disturb inner dressings unless saturated, but also acknowledging that there was no consistent oversight of wound care orders and no formal double‑check process for order entry. The DON confirmed that the facility’s order entry policy did not address verification or double‑checking of newly entered orders and described the process in which LPNs entered orders from paper or faxed documents without a structured second review.

The resident, who was cognitively intact and made their own healthcare decisions, reported that the day after the second Apligraf was applied, a nurse reacted to the appearance of the heel, left the room, returned with supplies, wetted the wound, and pulled pieces of the graft off. The resident stated that the same nurse later returned with another nurse and re‑did the dressing. The resident did not report this to facility staff at the time but informed the wound clinic at the next scheduled visit. At the 11/11/25 wound clinic appointment, wound care staff documented that when the dressing was removed, the Apligraf was missing and the wound contained a significant amount of boggy, non‑viable hypergranulation tissue, and the resident required surgical debridement and IV antibiotics. Wound clinic staff and podiatry office staff confirmed there were no calls from the facility to clarify orders or report removal of the graft. Facility staff interviews indicated that one nurse told the scheduler that another nurse had removed the Apligraf because the nurse did not see the new order, and that this information was not escalated to leadership. The DON stated they were not aware that the graft had been removed and acknowledged that the wound care orders were ambiguous.

Additional documentation from wound care, infectious disease, vascular surgery, and podiatry after the hospitalization described the subsequent management of the resident’s heel wound, including diagnoses of calcaneal osteomyelitis and partial calcanectomy, and the use of IV and oral antibiotics. These records confirmed that the graft was no longer present at the time of the 11/11/25 visit and that the wound had worsened. The wound clinic nurse explained that the Apligraf requires at least 48 hours to adhere and that the 11/3/25 order specified no dressing changes, verifying that the graft should not have been removed. The combination of delayed and incomplete order entry, lack of a verification process for new orders, staff confusion about wound care instructions, and failure to clarify or communicate with the podiatry or wound clinic providers led to the Apligraf being removed contrary to orders and not being reported, constituting the cited deficiency in providing care according to physician orders.