Failure to Provide and Accurately Document Daily Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to provide daily wound treatments and dressing changes as ordered for a resident who sustained a left lower leg laceration requiring nine sutures after being injured during a transfer by facility staff. Hospital discharge instructions and a physician order dated 2/7/26 directed staff to cleanse the wound on the left lower extremity with wound cleanser and cover it with xeroform, maxorb, an abdominal pad, and kerlix dressing every day shift. Review of the February 2026 Treatment Administration Record (TAR) showed no documentation that wound treatments or dressing changes were provided on 2/11/26 or 2/12/26. The resident’s private caregiver reported that on those two days the dressing was not changed at all and stated that she had to ask staff every day to change the dressing. On subsequent observation, the resident was seen with a gauze dressing on the left lower leg that had no date and later appeared dirty with a moderate amount of yellow drainage, with the caregiver stating that no dressing change had been done the previous day. Review of the TAR on 2/24/26 showed no wound treatment or dressing change documented for 2/23/26. New entries had been added to the TAR indicating that the DON had provided wound care on 2/11/26 and 2/12/26, but in interview the DON admitted she had not performed the wound care on those dates and had entered her initials the previous night because she was told by corporate to never leave charting blank. The facility’s Wound Treatment Management policy required that wound treatments be provided in accordance with physician orders, including cleansing method, type of dressing, and frequency of dressing change.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.