F0686

J

Failure to Timely Implement Wound Care Orders and Manage Refusals Resulting in Worsening Stage 3 Pressure Injury

Floresville, Texas Survey Completed on 01-04-2026

Penalty

Fine: $21,645

Summary

The deficiency involves the facility’s failure to provide pressure ulcer care consistent with professional standards of practice and to prevent the development and worsening of a pressure injury for one resident. The resident was an adult with diabetes, morbid obesity, and severe protein-calorie malnutrition, and was identified as at risk for pressure ulcers on a quarterly MDS, with no unhealed pressure ulcers at that time. A previously resolved stage 3 pressure ulcer on the left buttock was reported by a CNA on 10/26/2025 as having reopened, but the resident repeatedly refused skin and wound assessments by the DON, charge nurse, and Wound Care NP over multiple documented dates in late October and November. Despite these refusals, the facility’s care plan for a stage 3 pressure injury was not created and revised until 12/31/2025, 41 days after the ulcer was assessed and identified on the left buttock, and the care plan incorrectly referenced the right buttock and did not include interventions addressing the resident’s refusals.

On 11/20/2025, the Wound Care NP assessed the resident and identified a reopened stage 3 pressure ulcer on the left buttock measuring 4 cm x 5 cm x 0.2 cm, with recommendations to cleanse with 0.25% Dakins solution, apply collagen with silver, and cover with a silicone bordered superabsorbent dressing. These wound care recommendations were not implemented in the physician orders until 11/28/2025, resulting in an 8‑day delay in initiating the ordered treatment. During this period and afterward, the resident frequently refused wound care and incontinent care. TARs showed multiple refusals of daily wound care from late November through December, and weekly wound observations documented that the resident was mostly non-compliant with recommended interventions, frequently declined bed baths, and frequently refused to be changed by staff. Nursing notes indicated that staff attempted redirection, offered choices of caregivers, and modified approaches, but the refusals persisted.

On 12/24/2025, concerns about the resident’s hygiene, skin integrity, and personal care needs prompted further nursing evaluation. CNAs and LVNs reported that the resident had been refusing incontinent care and showers for days, and when staff ultimately provided a bed bath, they observed maggots in the resident’s bed, groin area, and in feces, as well as in association with the wound. The DON’s weekly wound observation on that date documented that the stage 3 pressure injury on the left buttock had increased in size to 6 cm x 3.5 cm x 2 cm. Interviews with CNAs and LVNs confirmed that refusals were reported to nurses, that staff made repeated attempts to persuade the resident to accept care, and that the resident sometimes delayed or continued to refuse care despite education. The Wound Care NP stated she had not been able to reassess the wound after 11/20/2025 due to ongoing refusals and continued the prior treatment order without change. An Immediate Jeopardy situation was identified on 01/02/2026 related to the failure to timely implement wound care recommendations and to effectively manage and escalate the resident’s ongoing refusals of care in the context of a worsening stage 3 pressure injury.

The facility’s own Pressure Injury Prevention Program policy required risk assessment at admission, quarterly, and with significant change in condition, as well as weekly skin checks and timely adjustment of interventions based on assessment findings. Despite this, the resident’s reopened wound identified by CNA report on 10/26/2025 and confirmed by the Wound Care NP on 11/20/2025 did not result in a timely, accurate, and fully developed care plan, and the wound care orders recommended on 11/20/2025 were not implemented until 11/28/2025. Documentation showed repeated refusals of wound care and personal care, but the care plan lacked specific interventions addressing these refusals, and there was no documented explanation from the DON for the delay in starting the recommended wound treatment. These actions and inactions led to the resident’s stage 3 pressure injury worsening in size and to the presence of maggots in the wound and surrounding areas on 12/24/2025, forming the basis of the cited deficiency.