F0686

D

Failure to Document Weekly Wound Assessments and Implement Wound Clinic Orders for Chronic Pressure Injury

Palisade, Colorado Survey Completed on 02-05-2026

Penalty

No penalty information released

Summary

Surveyors identified a deficiency in the facility’s provision of pressure ulcer care and prevention when a resident with multiple chronic pressure injuries did not receive care consistent with professional standards and facility policy. The resident, who was over 65 years old and cognitively intact, had paraplegia and multiple documented pressure ulcers, including stage 4 ulcers of the sacrum, left buttock, and both ankles, as well as a non‑pressure chronic ulcer of the right foot with fat layer exposed and osteomyelitis of the vertebra, sacrum, and sacrococcygeal region. The resident’s care plan called for weekly assessment and documentation of wound healing, including measurements and evaluation of the wound perimeter, wound bed, and healing progress, with changes to be reported to the provider.

Despite these requirements and the facility’s Pressure Injury Prevention and Management policy, the facility failed to complete and document weekly wound assessments in the electronic medical record (EMR) for the resident’s chronic wounds. The policy required weekly documentation of location, stage, size, depth, undermining or tunneling, exudate characteristics, pain, wound bed description, wound edges, surrounding tissue, and pressure‑reducing surfaces. However, surveyors found missing weekly wound assessment forms in the EMR for multiple weeks, specifically 10/5/25, 10/26/25, 11/2/25, 11/16/25, 11/23/25, 11/30/25, 12/21/25, and 12/28/25. Additionally, wound tracking logs maintained by the DON for some weeks contained only measurements without documentation of wound bed, periwound tissue, or exudate, and there were weeks with no corresponding outpatient wound clinic notes.

The facility also failed to follow and incorporate into physician orders the treatment recommendations made by an outpatient wound clinic nurse practitioner for the resident’s right lateral foot wound. Existing physician orders directed staff to cleanse the wound with wound cleanser, apply cavilon skin prep to the periwound tissue, and apply a foam border dressing three times per week and as needed. On two separate occasions, the outpatient wound clinic nurse practitioner documented recommendations to cleanse the right lateral foot wound with wound cleanser, apply calcium alginate and a dry dressing, and change the dressing daily and as needed if dislodged, saturated, or soiled. However, the treatment administration records for January and February showed that the facility did not update the wound care orders to reflect the daily dressing change frequency recommended by the outpatient provider, and the DON later stated she was not sure if the nurse practitioner had recommended any changes to the wound care orders.

Interviews with facility leadership further confirmed the documentation and treatment discrepancies. The DON reported that she completed weekly wound care assessments and measurements but did not consistently enter these assessments into the EMR, believing that outpatient wound clinic notes were sufficient when the resident had clinic appointments. She maintained a separate spreadsheet log of wound measurements, but this log lacked full descriptive details required by policy for certain weeks and did not cover all weeks where EMR documentation was missing. The regional consultant acknowledged that inconsistent wound assessment documentation had been identified, and the NHA and DON described concerns about the accuracy of measurements from the outpatient wound clinic nurse practitioner, but these issues did not change the fact that the facility’s own records lacked complete weekly wound assessments and that the outpatient clinic’s updated treatment recommendations were not reflected in the resident’s active wound care orders.