F0686

D

Failure to Implement Revised Wound Specialist Orders for Deteriorating Pressure Ulcer

Winter Garden, Florida Survey Completed on 02-04-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to implement revised wound specialist orders for a deteriorating pressure injury, and failure to update the care plan and documentation accordingly. A female resident with dementia, muscle weakness, a right femur fracture, and a stage 2 pressure ulcer on the left lower back was admitted and later re-admitted after hip fracture surgery. The admission MDS identified one unhealed stage 2 pressure ulcer present on admission, and a subsequent discharge-return-anticipated MDS identified one unhealed stage 2 pressure ulcer not present on admission during the look-back period. Despite this, the resident’s most recent care plan did not include a pressure wound. The Wound Care Specialist PA assessed the back wound as a stage 3 pressure injury and ordered treatment with Normal Saline, collagen, and honey gel, covered with border gauze. The Wound Care Nurse’s weekly evaluation documented only collagen as the current treatment.

A week later, the Wound Care PA documented that the wound was deteriorating and revised the orders to cleanse with Normal Saline, pat dry, apply Santyl nickel thick to the wound bed, then apply calcium alginate and cover with border gauze daily and as needed. Subsequent PA documentation showed further deterioration, with bone exposure and restaging of the wound to stage 4, along with a significant increase in wound size and volume. The PA ordered continued treatment with Santyl, calcium alginate, and Xeroform over the exposed bone, and requested imaging to rule out suspected osteomyelitis. However, review of the physician’s orders and TARs showed that the only wound treatment orders in place from the time of the revised orders until the resident’s discharge to the hospital remained the original regimen of Normal Saline, barrier cream to the peri-wound, collagen to the wound bed, and border gauze. None of the PA’s revised orders, including the imaging recommendation, were entered or implemented.

The Wound Care Nurse, an LPN, stated that her usual practice was to receive verbal orders from the Wound Care PA and transcribe them from his progress notes within a day, and that timely entry of treatment orders was important so they could be carried out. She acknowledged that a weekly wound evaluation note was entered two weeks late and stated she had “got a little behind.” In a joint interview with the DON, the LPN reported that she recalled receiving verbal orders from the resident’s PCP to override the Wound Care PA’s revised treatment orders and to leave the previous orders unchanged, but she had not documented these verbal orders, did not recall informing the PA, and there were no progress or treatment notes reflecting this. The DON confirmed that the PA’s revised orders were not entered, that the X-ray to rule out osteomyelitis was never ordered, and that she could not explain why these orders were missed. The Medical Director stated he relied on the Wound Care Specialist for pressure wound care and that an X-ray was not ordered because he believed it could not detect osteomyelitis and the resident was scheduled to see the orthopedic surgeon, whose office note later did not address suspected osteomyelitis or the pressure wound. The facility’s policies required that physician orders be followed as prescribed, that any orders not followed be recorded in the medical record with physician notification, and that the plan of care include revised interventions as indicated by the resident’s condition; these requirements were not met in this case.

During this period, the Wound Care Nurse’s weekly wound evaluations documented wound decline and listed “n/a” under other interventions, while current treatment entries eventually reflected Xeroform, Santyl, and calcium alginate but were completed two weeks after the evaluation date. The Wound Care PA reported that he gave verbal orders during assessments, printed notes for transcription the same day, and relied on the nurse to enter and implement the orders; he did not recall any of his orders being overridden by the PCP and noted that dressings were typically removed before his assessments, preventing him from knowing what dressing was in place. The resident’s PCP follow-up notes over multiple visits did not address pressure wound assessment or care, listing only other medical diagnoses. The resident was ultimately admitted to the hospital, where records showed treatment for an infected mid-back pressure wound, MRSA bacteremia, and sepsis, and she later died. A letter from the Medical Director and PCP written after the survey stated that, seeing the previous treatment had worked well, an order was given to continue the previous treatment, but this was not contemporaneously documented in the resident’s record. The facility’s failure to implement the wound specialist’s revised orders, to document and communicate any overriding PCP orders, to update the care plan, and to follow its own policies on physician orders and pressure injury prevention constituted the identified deficiency.

The resident’s daughter reported that she was informed by the facility’s Wound Care Nurse that the wound measured 2 cm about a week before the resident’s rehospitalization, and later learned from hospital staff that her mother had a severe, large, infected spinal wound with exposed bone requiring six weeks of IV antibiotics and a special infusion catheter. She described that her mother looked terrible, rapidly declined, and was unable to communicate while hospitalized. These accounts, along with the hospital documentation of an infected mid-back pressure wound and MRSA bacteremia, were part of the surveyors’ findings related to the facility’s failure to provide appropriate pressure ulcer care and to prevent the development and worsening of pressure injuries.