F0686

K

Failure to Provide Ordered and Proper Pressure Ulcer Care for Two Residents

Arlington, Texas Survey Completed on 01-10-2026

Penalty

Fine: $187,220

Summary

The deficiency involves the facility’s failure to provide necessary pressure ulcer treatment and services, consistent with professional standards of practice, for two residents with pressure ulcers. One resident, an older female with cancer, heart failure, and sepsis, was admitted without pressure ulcers but was identified on 12/09/25 as being at risk for skin alterations with an unstageable wound to the buttock. Her care plan interventions included monitoring for signs and symptoms of infection, monitoring treatment effectiveness, notifying the physician as needed, and performing weekly skin assessments. A physician order dated 12/18/25 directed staff to cleanse the coccyx with wound cleanser or normal saline, apply collagen, and cover with a dry dressing once daily. The Treatment Administration Record showed the ordered wound treatment was not completed on 12/19/25, and although LVN C documented treatment on 12/20–12/21, the Wound Care Nurse’s (WCN) initials appeared for 12/22–12/25 without the WCN recognizing or confirming those entries.

Progress notes documented that on 12/18/25 a skin check identified a reopened wound to the sacrum and open areas to the left and right buttocks, with education provided on treatment and turning every two hours. On 12/22/25, a weekly skin/wound note by the WCN stated the sacral pressure injury was assessed and treated per order, with the wound cleansed and dressing changed, but no measurements or detailed wound characteristics were documented. On 12/24/25, the Wound Care Nurse Practitioner performed a first evaluation of the coccyx pressure ulcer, describing it as an unstageable pressure ulcer measuring 4.5 cm x 4.5 cm x 3.5 cm with 40% granulation, 40% slough, and 20% eschar, malodorous drainage, fragile and ecchymotic peri-wound tissue, and non-blanchable maroon discoloration. The Nurse Practitioner ordered Dakin’s solution for cleansing, iodoform packing, and a superabsorbent dressing to be changed every other day, and noted that a sharp debridement was not performed at that time. The Nurse Practitioner reported she was not notified about the wound until she arrived on 12/24/25 and that the facility had no wound culture supplies when she requested a culture.

Interviews revealed multiple failures in assessment, treatment, and communication for this resident’s wound. CNA B reported first seeing the open wound on 12/18/25 and notifying LVN A, who estimated the wound to be about the size of a dime, obtained an order from the WCN, but did not personally treat or subsequently visualize the wound, assuming the WCN would do so. CNA C, who bathed the resident, noticed the wound looked more open on 12/21/25 and notified a nurse, stating that each time he saw the wound it had cream on it. LVN D, who performed wound care on 12/20–12/21, described the wound as about the size of a quarter, not very deep, and without drainage, and reported using calcium alginate and a dry dressing. The WCN stated she saw the wound on 12/22/25 and 12/24/25, described it on 12/22/25 as about the size of a tangerine and curved in but did not measure or document its size, and acknowledged she did not notify the facility physician of the wound and did not document her phone contact with the Nurse Practitioner on 12/22/25. The DON stated she never looked at the wound, and the facility physician confirmed he was only notified about the wound on 12/18/25 and was not informed of any subsequent changes or suspected infection. The resident’s responsible party reported the facility had described the area only as a “hot spot,” did not disclose the severity, and that when the resident was taken home for a holiday dinner on 12/25/25, the responsible party observed a large, dark, unstageable coccyx ulcer with necrotic tissue and a separate Stage II ulcer on the right lower buttock, then took the resident to the hospital, where the emergency department physician documented an unstageable decubitus ulcer with foul odor and necrotic tissue.

The deficiency also includes improper wound care technique for a second resident with a Stage III sacral pressure ulcer and diabetes. This resident’s care plan required assessment and documentation of wound appearance, including size, depth, exudate, tissue type, odor, and location during dressing changes, and a physician order directed daily cleansing with wound cleanser, application of medical grade honey, and a bordered dressing. During an observed wound care procedure, the WCN sprayed wound cleanser on and around the ulcer, then used gauze to clean only the skin around the wound, leaving wound cleanser in the ulcer itself. After measuring the wound length, the WCN changed gloves while the DON held the resident’s left buttock away from the ulcer; when the DON briefly released the buttock, it fell onto the ulcer. The WCN then resumed care without re-cleansing the wound until prompted by a question about whether she would clean the wound, at which point she sprayed cleanser again but initially still did not remove it from the ulcer bed. Only after further questioning did the WCN use gauze to clean the wound cleanser off the ulcer and surrounding skin before applying the ordered treatment and dressing. Both the DON and the WCN later acknowledged in interviews that it was important to cleanse the ulcer and surrounding skin, and to re-clean the wound if the buttock touched it, and to remove wound cleanser from the ulcer to avoid transferring bacteria into the wound.

Removal Plan

• Assess all residents with wounds and communicate the current condition of each wound with the resident's physician and the wound care nurse practitioner to ensure proper treatments are in place to treat and heal the wounds.
• Provide education to the Director of Nursing, Treatment Nurse, and Assistant Director of Nursing on the Change in Condition policy as it relates to physician notification, following orders that promote healing and prevention of pressure ulcers, and documenting all characteristics of wounds, including measurements.
• Provide education to all nurses on the Change in Condition policy as it relates to physician notification.
• Provide education to all nurses, including the treatment nurse, on documenting all characteristics of wounds, including measurements, and following physician orders related to healing and preventing pressure ulcers.
• Complete a competency test with nurses related to physician notification, following orders that promote healing and prevention of pressure ulcers, and changes in skin.
• Designate the Treatment Nurse to complete wound care and assign coverage by the Assistant Director of Nursing, Director of Nursing, or a designated nurse when the Treatment Nurse is unavailable, with weekend wound care completed by the weekend supervisor or assigned charge nurse.
• Have the Director of Nursing and/or designee observe wounds to ensure documentation and proper notification are charted, immediately address discrepancies or concerns with the resident's physician and wound care practitioner, provide reeducation as needed, and review the wound care nurse practitioner's notes to ensure no additional concerns are noted.
• Perform an ad hoc QAPI with the Medical Director to review the IJ template, identify the root cause of the deficient practice, and discuss the facility's plan to remove the immediacy.