F0686

D

Failure to Consistently Provide Ordered Pressure Ulcer Care Resulting in Wound Deterioration

West Palm Beach, Florida Survey Completed on 02-24-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide ordered pressure ulcer care and promote healing of a facility-acquired sacral pressure ulcer for one resident with severe cognitive impairment, dementia, total dependence for ADLs, weight loss, two stage 3 pressure ulcers, and continuous bowel and bladder incontinence. The resident was care planned as at risk for skin breakdown with interventions including frequent turning and repositioning, keeping the skin clean and dry after each incontinent episode, and use of a low air loss mattress. The resident was also care planned for left buttock and sacral pressure ulcers with interventions to administer treatments as ordered and provide frequent incontinent care. Wounds to the left buttock and sacrum were first identified by a CNA and documented as stage 3 pressure ulcers by wound care on 01/13/26.

Physician orders dated 01/15/26 required daily wound care and as-needed dressing changes if soiled, wet, or dislodged, but the MAR showed wound care was not completed on 01/16/26 with no documented reason. On 01/21/26, wound care documentation showed the left buttock wound had resolved while the sacral wound had deteriorated, and wound care orders were increased to twice daily. The MAR then showed that the ordered evening wound care on 01/22/26 was not done, again without explanation. Subsequent wound care notes documented that the sacral wound further deteriorated to a stage 4 pressure ulcer, with a wound culture later positive for three different bacteria and an x-ray confirming osteomyelitis. The wound care nurse confirmed that the left buttock wound resolved but the sacral wound deteriorated after initially being identified as a stage 3 pressure ulcer.