F0684

D

Failure to Consistently Complete and Document Ordered Wound Care and Skin Checks

Pana, Illinois Survey Completed on 02-26-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide wound care and daily skin checks as ordered for a resident with multiple comorbidities and documented venous and non-pressure wounds. The resident, cognitively intact and dependent on staff for most ADLs, had care plan interventions requiring ongoing wound assessment and documentation, including weekly measurements and monitoring for signs of infection. Physician orders directed daily skin checks on day shift with CROPs documentation on the TAR each Friday, and nightly dressing changes to the right anterior lower leg with specific cleansing and dressing procedures. Review of the Treatment Administration Records (TARs) for December, January, and February showed multiple dates where daily skin checks and ordered dressing changes were not documented as completed.

On observation, the resident was seen in a wheelchair with a right lateral ankle dressing dated the previous day and showing a moderate amount of yellow/green drainage, and the resident reported that the dressing, usually changed by night shift, had not been changed the prior night when agency staff were working. Interviews with LPN staff indicated that many agency nurses do not complete ordered treatments, with one LPN stating she found dressings unchanged two days after she had last performed them, and another describing dressing changes on night shift as “hit or miss,” particularly when agency staff were on duty. The regional nurse stated she expects dressings to be changed as ordered. The facility’s wound care policy requires detailed documentation of wound care, including type of care, date and time, assessment data, resident tolerance, and any problems or refusals, which was not consistently reflected in the TARs for this resident.