F0686

D

Failure to Provide and Document Ordered Pressure Ulcer Treatments

Merrillville, Indiana Survey Completed on 02-26-2026

Penalty

No penalty information released

Summary

The facility failed to provide ordered pressure ulcer treatments for a resident with pressure ulcers on the coccyx and left heel who had adult failure to thrive, significant cognitive deficits, and required substantial to maximum assistance for bed mobility. A physician’s order dated 12/20/25 directed daily cleansing of the coccyx wound with normal saline, application of calcium alginate, and coverage with a dry dressing; however, the January 2026 Treatment Administration Record showed this treatment was not signed out as completed on 1/5 and 1/7.

For the left heel wound, multiple physician’s orders were in place over time, including orders for cleansing with normal saline, application of calcium alginate, securing with Kerlix on specific days of the week, and later adding triple antibiotic ointment to the peri-wound area before applying calcium alginate and a dry dressing. These orders were revised and discontinued on several dates, with a final order for daily treatment starting 1/31/26. The January and February 2026 Treatment Administration Records indicated the left heel wound treatments were not signed out as completed on 1/5, 1/7, 1/25, 1/31, 2/9, 2/16, and 2/17. During interview, the Wound Nurse stated she did not know why the treatments were not completed on those dates and noted that some February dates corresponded with hospice visits, but hospice records requested were not received. The facility’s Wound Dressing Change policy required documentation of dressing changes on the treatment record.