Failure to Follow Wound Care and Blood Pressure Monitoring Orders
Penalty
Summary
The deficiency involves the facility’s failure to follow physician orders and provide wound care and monitoring according to professional standards for two residents. One resident with chronic osteomyelitis, bilateral foot ulcers with necrosis of bone, toe amputations, diabetes, and sepsis was admitted with active treatment orders on the TAR for nightly and as-needed dressing changes to bilateral lower extremities, including monitoring for infection, documenting drainage, and documenting pain scores. The resident’s initial care plan did not address wounds or wound care interventions. Surveyor review of the TAR showed no documentation of daily assessments or dressing changes from 1/5/26 to 1/10/26, despite the active orders. When observed, the resident’s foot dressings were loosely wrapped, and the resident reported having wounds on both feet and not believing dressing changes had been done since admission. An LPN stated the dressing changes were done as needed and would be documented in the TAR, but the TAR lacked entries for the specified dates. The DON confirmed that the TAR orders required daily dressing changes and that documentation only showed dressing changes on 1/11 and 1/12/26, indicating the dressings were not changed on 1/5 through 1/10/26. The second resident, with hypertension, chronic kidney disease, and cognitive decline, experienced a fall from a recliner and was found on the floor, incontinent but alert and oriented, with vital signs stable except for low blood pressure. The nurse documented that the NP was notified and instructed staff to push fluids and assess blood pressure every hour to determine if hospital transfer was needed, and to hold all blood pressure medications until blood pressure reached proper levels. The MAR showed antihypertensive medications were held on the day of the incident, and all medications were administered as ordered on the following two days, including the morning of 12/23/25. However, surveyor review could not locate documentation of blood pressure readings after the initial incident, nor documentation that medications were held as ordered beyond what appeared on the MAR. The DON stated she was unable to find documentation that nursing staff followed the NP’s orders to monitor blood pressure until it reached acceptable levels or that medications were held as directed.
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