Failure to Provide Ordered Wound Care and Care Planning for Pressure Ulcers
Penalty
Summary
The deficiency involves the facility’s failure to provide pressure ulcer and wound care in accordance with physician orders and professional standards for one resident with multiple heel wounds and a sacral pressure ulcer. The resident was admitted and later readmitted in 2025 with blisters on both heels, and the left heel healed by 3/10/25 while the right heel remained open and required ongoing wound treatment. Review of the Treatment Administration Records (TARs) from February through August 2025 showed that wound treatment orders for various heel wounds (including abrasions, blisters, a deep tissue injury, and a diabetic ulcer on the right lateral heel) were not consistently carried out, as evidenced by multiple missing nurse signatures on ordered treatment days. The DON confirmed that if there was no signature, the treatment was not done and acknowledged multiple missed wound treatments on specific dates across several months. The report further describes that the resident developed a stage 2 pressure ulcer on the sacrum that was present upon return from a hospitalization in July 2025. Although the sacral wound was identified on the resident’s return from the hospital, the facility did not obtain a physician’s wound treatment order promptly. As a result, no ordered wound treatment was provided on several days following the resident’s readmission, even though weekly wound assessments later documented dressing changes and treatment beginning on a later start date. The DON confirmed that staff missed obtaining a wound treatment order for the sacral pressure ulcer during this period, and therefore wound treatments were not performed on the specified days. Additionally, the facility failed to develop a care plan to address the resident’s stage 2 sacral pressure ulcer. Review of the resident’s care plans showed no care plan in place for this pressure ulcer, despite facility policies requiring a comprehensive, person-centered care plan with measurable objectives and timetables to meet residents’ needs, and policies on prevention/management of pressure ulcers that call for reviewing the care plan and identifying risk factors and interventions. The DON reviewed the clinical record and confirmed that there was no care plan addressing the sacral pressure ulcer.
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