F0684

G

Failure to Provide Ordered Wound Care, Infection Control, and Skin Tear Prevention

Mattoon, Illinois 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 management according to physician orders, facility policies, and resident needs for two residents. For one resident with multiple lower extremity lymphedema wounds, the facility did not ensure that wound care orders from an outside wound clinic were accurately transcribed and clarified, and the resident’s leg wound treatment orders were not placed on the Treatment Administration Records for November and December. The wound clinic ordered daily wound care, while the physician orders in the facility reflected wound care three times weekly tied to lymphedema treatments, with no documentation that this discrepancy was clarified. After a wound/skin assessment documented multiple leg wounds and their measurements in mid-December, there were no further documented wound assessments in the medical record until the resident was seen again at the wound clinic in early January, except for one refusal with no documented follow-up attempts.

During this period, a Physical Therapy Assistant (PTA) performed lymphedema treatments and wound dressing changes three times weekly, but the PTA’s notes did not document wound characteristics or specific treatments. The PTA reported that the resident’s wounds deteriorated, with increased drainage and odor, and lymphedema therapy was stopped when the wounds began draining copious green fluid. Nursing notes documented a significant decline in the leg wounds with purulent green drainage and foul odor, and a wound culture was ordered along with oral antibiotics; however, the culture could not initially be obtained due to lack of culture kits. Later, a wound culture showed drug-resistant organisms. An infectious disease consultation documented that the resident’s wound dressings had not been changed for an extended period, with purulent drainage weeping through the dressings and foul odor, and that the resident required hospitalization for worsening chronic leg wounds and concern for infection. Hospital discharge instructions listed cellulitis of both legs, complicated wound infection, polymicrobial bacterial infection, and MDR Acinetobacter baumannii infection. The January Treatment Administration Record also showed multiple days when leg wound treatments were not signed as administered, and the resident reported that leg dressings were supposed to be changed daily but were sometimes forgotten.

The facility also failed to implement appropriate infection control practices during wound care for this resident. The PTA reported that the resident was not on Transmission-Based Precautions or Enhanced Barrier Precautions and that a gown was not worn during wound treatments, despite the resident having open wounds. The PTA described performing hand hygiene before and after treatment but not routinely during glove changes, stating that hand hygiene during the procedure was only done if hands were visibly soiled, which did not align with the facility’s hand hygiene policy requiring hand hygiene with each glove change. The DON later confirmed that Enhanced Barrier Precautions should be implemented for open wounds and that a gown should be worn during wound care, and that hand hygiene should be performed with each glove change.

For a second resident with severe cognitive impairment, the facility failed to develop and implement interventions to prevent recurrent skin tears. Incident reports documented that this resident, who self-propelled in a wheelchair, sustained a skin tear to the left lower leg and shin after hitting the leg on the bed, and then a subsequent skin tear to the left knee after bumping the knee while in the wheelchair. Despite these repeated skin tears, there was no documentation in the medical record of any interventions being developed or implemented to protect the resident’s skin from additional tears. The DON confirmed that there were no documented skin interventions following these incidents.