F0656

K

Failure to Develop and Implement Comprehensive Wound Care Plans and Follow Existing Wound Interventions

Arlington, Texas Survey Completed on 01-10-2026

Penalty

Fine: $187,220

Summary

The deficiency involves the facility’s failure to develop and implement comprehensive, person-centered care plans with measurable objectives and timeframes for residents with wounds, and failure to follow an existing wound care plan. For one resident, a female with moderately impaired cognition and diagnoses including cancer, heart failure, and sepsis risk, the care plan identified her as at risk for skin alterations and documented an unstageable wound to the buttock. The care plan interventions included monitoring the site for signs and symptoms of infection, monitoring treatment effectiveness, notifying the physician as needed, and performing weekly skin assessments. Physician orders dated mid-month directed specific wound care to the coccyx, but the treatment administration record showed at least one missed treatment. Progress notes documented a reopened wound to the sacrum and buttocks and a weekly skin/wound note indicated an unstageable coccyx pressure injury with malodor, necrotic tissue, and detailed wound characteristics. Despite these findings, there was no evidence that the wound was consistently monitored for infection or that the physician was notified of changes in the wound’s condition.

On the day of a family outing, nursing documentation reflected that the resident was described as stable and left with her responsible party for holiday celebrations with portable oxygen. The facility had previously informed the responsible party only that the resident had a “hot spot” on her bottom and was receiving treatment, without disclosing the severity of the wound. That same evening, the responsible party observed the wound at home, described it as large, dark, and unstageable with necrotic tissue and surrounding deep red tissue, and took the resident to the hospital. Emergency department documentation noted an unstageable decubitus ulcer to the coccyx with foul odor and necrotic tissue. Interviews revealed that the CNA who first saw the open wound on the resident’s buttocks notified an LVN, who estimated the wound as dime-sized but did not measure it and did not continue to visualize it after the initial date. Another CNA later reported noticing the wound appearing more open and notified a nurse. The wound care nurse practitioner evaluated the wound several days before the outing, documented an unstageable coccyx pressure ulcer with significant slough and eschar, ordered Dakin’s solution and iodoform packing, and requested a wound culture, but stated she was not notified about the wound until she arrived at the facility and that the facility should have notified her or the physician before the wound worsened. The facility physician confirmed he was only notified once about the wound and did not assess it between its identification and the resident’s transfer out.

A second resident, a male with intact cognition and diagnoses including heart failure, wound infection, paraplegia, malnutrition, and chronic bone infection, had documented wounds including a Stage III pressure ulcer and chronic leg ulcers. His care plan addressed only a non-pressure chronic ulcer to the right leg, with interventions to monitor and document the wound’s location, size, and treatment, and to report abnormalities and signs of infection to the physician. There was no care plan in place for his chronic ulcer on the left leg or for the pressure ulcer on the sacrum, despite physician orders for wound care to both lower legs and the coccyx. Additionally, this resident was not listed on the facility’s wound report, even though the wound care nurse and DON acknowledged he had a pressure ulcer and two leg wounds and that the wound care nurse had already been providing wound care. The wound care nurse stated she was responsible for ensuring wound care plans were written and used them to educate staff, but could not explain why the care plan for the first resident was not followed or why the second resident lacked care plans for all of his wounds. The facility’s own policy required comprehensive, person-centered care plans with measurable objectives and timeframes that describe services to meet residents’ physical, mental, and psychosocial needs, but the documented practices for these two residents did not meet those requirements.

The situation for the first resident escalated to an Immediate Jeopardy determination after it was identified that the resident’s wound site was not monitored for signs and symptoms of infection, the effectiveness of treatment was not evaluated, and the physician was not notified of wound changes, despite the presence of an unstageable coccyx pressure ulcer with necrotic tissue and malodor. The resident was taken out of the facility by her responsible party, who then sought emergency care after observing the wound. Hospital records documented an unstageable decubitus ulcer with foul odor and necrotic tissue, and the responsible party reported being told the resident had sepsis possibly due to the wound and that the resident later died. For the second resident, the absence of care plans for all documented wounds and the omission from the wound report represented additional failures to ensure that comprehensive, person-centered care plans were developed and implemented for residents with wounds, as required by facility policy and regulatory standards.

Removal Plan

• Resident #3's care plan was updated to reflect the current state of their wound and interventions per the interdisciplinary team's discussion.
• All residents with wounds were reviewed to ensure the care plans are reflecting the residents' current wound status.
• Regional Nurse Consultant will educate Director of Nursing, Assistant Director of Nursing, Treatment Nurse, and MDSC Nurse over the care plan policy with emphasis on care planning wounds (wound location, type, stage), following physician orders, and ensuring care plans are comprehensive person-centered, consistent with resident rights, and include measurable objectives and time frames to meet medical, nursing, mental and psychosocial needs.
• All licensed nurses will be educated over the care plan policy with emphasis on care planning wounds (wound location, type, stage), following physician orders, and ensuring care plans are comprehensive person-centered, consistent with resident rights, and include measurable objectives and time frames to meet medical, nursing, mental and psychosocial needs.
• The Treatment Nurse and/or Designee will complete and update the care plans with any changes for wounds.
• The Director of Nursing or Designee will review the wound care plans to ensure they are present, accurate, and being followed.
• In Quality of Care meeting, the Director of Nursing, Assistant Director of Nursing, Treatment Nurse, and/or Designee will review residents with wounds, weekly wound report from wound care nurse practitioner, facility wound report, wound care orders, and wound care plans to ensure accurate information is present and documented.
• Ad hoc QAPI performed with Medical Director to inform them of the Immediate Jeopardy and the facility's plan to remove the immediacy.