Failure to Timely Implement and Update Wound Care Orders and Consult Recommendations
Penalty
Summary
The deficiency involves the facility’s failure to provide pressure ulcer and wound care in accordance with professional standards, specifically by not timely implementing physician orders for wound consults and treatments, and not updating treatment orders after wound consult recommendations. For one resident, a scheduled skin check identified new sacral redness on 01/04/2026, but the documentation did not further describe the skin impairment. A physician order for an in-house wound team consult was entered on 01/05/2026, yet the wound consult was not completed until 01/13/2026, nine days later, at which time a Stage 3 cluster wound on the coccyx was documented with specific measurements and tissue characteristics. For another resident, a change in condition note on 09/17/2025 identified a sacral skin wound/ulcer, and the physician provided specific wound care treatment instructions that same day, but the corresponding physician order for wound care to the left buttock pressure ulcer was not entered and implemented until 09/20/2025, three days after the wound was first identified and treatment was recommended. A third resident had a physician order dated 01/20/2026 for care of a left dorsal foot arterial ulcer, including cleansing with NSS, application of Xeroform, ABD pad, rolled gauze, and offloading in Prevalon boots every other day. A subsequent wound consult on 02/10/2026 for the same left dorsal foot ulcer recommended a different regimen: daily cleansing with soap and water, Xeroform, dry gauze/Kerlix, tape, and maintaining a Prevalon boot while in bed, per the surgeon’s request and facility protocol. However, the February 2026 treatment record still reflected the earlier every-other-day NSS-based order starting 01/22/2026 and was not updated to reflect the new daily treatment recommendations from the wound consult. In interviews, the DON confirmed that wound consult recommendations and physician orders are expected to be implemented immediately or by the following day, and the surveyors shared concerns regarding the timeliness of wound consult completion and implementation of wound-related physician orders.
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