F0684

E

Failure to Follow Wound Care Orders and Complete Weekly Skin Assessments

Saint Petersburg, Florida Survey Completed on 02-25-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide wound care and skin assessments as ordered and care planned for multiple residents with non-pressure wounds and skin integrity risks. For one resident with metabolic encephalopathy, repeated falls, and dementia, a physician’s order directed cleansing of right lower extremity skin tears with normal saline, application of xeroform and ABD pad, and gauze wrap every two days on night shift beginning 6/7/25. Documentation on the Treatment Administration Record (TAR) showed treatments recorded on 6/7, 6/9, 6/11, 6/13, 6/15, and 6/17/25. However, on 6/19/25 the DON documented that the dressing on the right lower extremity was dated 6/11, despite two nurses having signed that dressing changes were completed on 6/13, 6/15, and 6/17, indicating the ordered dressing changes were not actually performed as documented. Weekly skin evaluations for this resident on 6/14/25 indicated the skin was not intact and the areas were not new, but the progress notes for that date did not include information about the skin evaluation or the existing areas.

For the same resident, an order on the TAR required monitoring steri-strips on the left hand for signs and symptoms of infection every shift. The TAR showed code “9” (other/see progress notes) on the day shift of 6/11 and the evening shift of 6/15, and a blank entry for the night shift on 6/12, indicating the monitoring was not documented as completed that shift. Progress notes on 6/11 documented wound care provided by the wound care nurse, but notes on 6/11, 6/12, and 6/13 did not explain why the steri-strip monitoring was not completed on the night shift of 6/12. A 6/15 progress note stated staff had not observed the steri-strips to the left hand. The resident’s care plan identified risk for skin breakdown related to assistance needs, nutritional risk, and prior skin tears, and included interventions for monitoring steri-strips for infection every shift, observing skin condition during routine care every shift, providing treatments as ordered, and weekly skin checks. During interview, the DON stated weekly skin checks were done head to toe but staff were focused on identifying new areas and did not pay attention to dressing dates, even though the care plan did not limit checks to new areas only.

Another resident with a left wrist skin tear had an order starting 2/13/26 for daily evening-shift treatment with normal saline, xeroform, and dry sterile dressing until resolved. The TAR showed completion from 2/13 through 2/18/26, with the 2/19/26 entry left blank, indicating the treatment was not documented as completed that day. A new order on 2/20/26 for daily day-shift treatment was started and discontinued the same day, while the dressing changes continued every other day thereafter (2/21, 2/23, 2/25/26) despite weekly skin inspections dated 2/14 and 2/21/26 documenting the skin as intact. The care plan for this resident identified potential for skin impairment related to decreased mobility, impaired cognition, incontinence, and a left wrist skin tear, and directed licensed nursing staff to provide treatments as ordered, but did not include weekly skin evaluations. During observation on 2/25/26, the LPN/Unit Manager stated the dressing change was every other day, and the dressing was dated 2/23/26, which did not match the documented daily treatment orders.

A third resident with a right wrist dressing reported that the dressing was changed frequently, and the LPN/Unit Manager stated the changes were every other day. However, the provider note documented an order to cleanse with normal saline, pat dry, apply xeroform, and dry dressing for four days, and the TAR showed the treatment order starting 2/19/26 with daily dressing changes documented for six days, without an end date entered as of 2/25/26. The resident’s electronic record showed the weekly skin inspection was two days overdue, with the last completed weekly skin inspection on 2/16/26 despite a care plan intervention for weekly skin checks by licensed nursing staff. The DON acknowledged that the weekly skin check for this resident was overdue. Overall, record reviews, observations, and interviews showed that wound treatments were not consistently provided as ordered, documentation on the TAR was inaccurate or incomplete, and weekly skin assessments were not completed timely or accurately for the sampled residents, contrary to the facility’s Wound Treatment Management policy requiring treatments per physician orders and ongoing assessment and documentation.