F0684

D

Failure to Transcribe and Implement Wound Care and Compression Pump Orders

Overland Park, Kansas Survey Completed on 02-24-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to correctly transcribe and follow wound care provider orders for a resident with a diabetic foot ulcer. The resident had type 2 DM with a foot ulcer, difficulty walking, and generalized muscle weakness, and was cognitively intact with a BIMS score of 15. Her care plan identified a diabetic foot ulcer on the left foot and interventions including administering treatments and supplements as ordered, obtaining labs as ordered, monitoring and documenting wound size and depth, and observing and reporting signs of infection. The Pressure Ulcer/Injury CAA documented that she was at risk for pressure ulcers due to decreased mobility and incontinence.

Consultant wound care orders dated 12/10 and 01/07 directed the use of pneumatic compression pumps two to three times daily for one-hour increments as tolerated. On 01/28, the wound care provider issued detailed left foot wound care orders specifying cleansing with Dakin’s solution for three to five minutes, applying A&D ointment around the wound, weaving InterDry between toes, applying Hydrofera Blue to the wound, covering with Drawtex and an ABD pad, and wrapping with a CoFlex calamine multi-layer compression wrap, with dressing changes to occur daily except on days the resident went to the wound care center, and continued orders for pneumatic compression pumps two to three times daily. The nurse’s note on 01/28 documented that the resident returned from the wound care provider with new lab and wound care orders but did not specify the content of those orders. Instead of entering the daily dressing change frequency, an order starting 01/30 was entered for dressing changes only on Monday, Wednesday, and Friday, and a later order starting 02/05 directed lymphatic pumps to be applied once daily at night for 60 minutes, without documentation of a corresponding provider order for that reduced frequency.

The wound care provider’s 02/04 progress note documented that the resident reported the facility was not using Dakin’s solution for wound cleansing as ordered, that the DME company confirmed delivery of the lymphedema pumps but staff had not used them, and that although daily dressing changes were ordered, the facility continued to perform dressing changes only two to three times per week. The provider also documented leaving several messages with the facility without response. On observation, the resident reported that her left foot dressing was not changed daily as ordered and that staff told her the compression dressing could stay on for a couple of days. Multiple administrative and licensed nursing staff interviews confirmed that the EMR still reflected a Monday/Wednesday/Friday schedule despite the 01/28 orders for daily dressing changes, that staff relied on wound care notes and sometimes had to call to obtain orders, and that the dressing change frequency had not been updated after the 01/28 visit. Staff also acknowledged that the facility learned of the compression pumps’ delivery only after finding them at the front of the building and that they should have followed up with the wound care provider regarding initiation of the pumps. Facility policies on wound care and medication/treatment orders required physician orders for procedures and administration of treatments only upon written orders, but did not address order transcription after appointments, and the failure to correctly transcribe and implement the wound care provider’s orders led to the identified deficiency.