F0686

D

Failure to Provide Ordered Pressure Ulcer Treatments and Timely Skin Assessment

Michigan City, Indiana Survey Completed on 02-10-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide ordered pressure ulcer treatments and to complete a timely skin assessment upon a resident’s readmission. The resident had multiple diagnoses including COPD, respiratory failure, diabetes, arthritis, heart failure, and a history of pressure ulcers, and had documented pressure ulcers to the left buttock, right buttock, and left ischial tuberosity related to immobility, incontinence, obesity, fragile skin, and prior ulcers. A care plan directed staff to provide wound treatments and nutritional supplements and to assist with offloading the lower extremities. Physician’s orders dated 12/11/25 required nightly cleansing of the left and right buttocks with soap and water, application of zinc barrier cream mixed with antifungal ointment, and coverage with bordered gauze. The December 2025 TAR showed these treatments were not signed out on three consecutive days, indicating they were not documented as completed.

Upon the resident’s return to the facility on 1/1/26, a nurse’s note documented that the resident arrived via stretcher, could make needs known, and that there were no changes in skin integrity, but the DON later confirmed that a skin assessment was not performed that day. A subsequent physician’s order on 1/2/26 directed nightly wound care with Dakin’s solution, Dakin’s-soaked gauze, calcium alginate, and bordered gauze. The January 2026 TAR indicated this treatment was not signed out on two consecutive nights. During interview, the DON acknowledged that the skin assessment should have been completed on the day of readmission and that the wound treatments should have been signed out, confirming the failure to follow physician’s orders and to complete a timely skin assessment for the resident with pressure ulcers.