F0686

J

Failure to Provide Ordered Wound Vac Therapy and Consistent Wound Care Resulting in Septic Shock

Niles, Michigan Survey Completed on 02-10-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide ordered wound care and monitor a complex stage IV sacral pressure ulcer, resulting in deterioration of the wound and subsequent hospitalization for septic shock and osteomyelitis. The resident was admitted with multiple wounds, including a stage IV sacral ulcer and a right buttock wound, and required assistance with personal care. Hospital records at admission documented deep decubitus ulcers, debridement with clean borders, placement of a wound vac, and a plan for a wound clinic follow-up in two weeks. The facility’s admission assessment noted wounds on the right iliac crest, left inner ankle, right outer ankle, and sacrum but did not include measurements or wound type descriptions for each area. The care plan identified risk for impaired skin integrity and set a goal for improvement with interventions such as pressure redistribution and reevaluation of treatment when there was no improvement.

Following admission, the facility did not consistently follow wound vac orders or ensure timely dressing changes. The Treatment Administration Record (TAR) for the sacral wound vac showed missing or incomplete documentation on multiple dates, including entries marked only as “see progress note” or left blank, and a hold on the wound vac from 12/29 to 12/31. Progress notes on 12/26 and 12/29 documented that wound vac supplies were reportedly unavailable and that attempts to change the wound vac dressing could not be completed due to lack of supplies. On 12/29, when the dressing was removed, nursing staff observed the right buttock wound down to bone, necrotizing tissue between buttock wounds, and a red, hot peri-wound area with odor. The former DON instructed staff to switch to wet-to-dry dressings and contact the wound clinic, and a nurse texted the NP about changing the dressing to wet-to-dry. However, there was no documented provider order authorizing the change from wound vac to wet-to-dry, and the NP later stated she had not recommended changing the wound vac orders and expected the wound vac to continue.

Throughout this period, wound assessments and treatments were inconsistently documented and some wounds lacked any treatment orders. Wound measurements on 12/24 and 12/31 showed stage IV wounds to the right buttock and sacrum with granulation, slough, odor, rolled edges, tunneling, and undermining, but there were no treatment orders in the TAR for the right ankle, left ankle, or right leg wounds. TAR entries for other wound locations, such as the left hip and right posterior ribs, also had missing documentation or notes that did not explain why treatments were held. One LPN documented “No wound care this shift” on 12/31 to remove the task from her list and acknowledged that she commonly skipped treatments due to workload, with no way to verify if another nurse completed the care. Another LPN documented only a period in progress notes where treatment status should have been recorded and could not recall whether treatments were missed. Staff interviews revealed that nurses believed they were out of wound vac supplies, while the clinical care coordinator and former DON stated supplies were available in storage. The medical records staff and several clinical leaders were unaware of the hospital’s order for a wound clinic follow-up on 1/1, and the resident did not attend that appointment; the facility instead submitted a referral on 12/31 and scheduled a later clinic date.

During this time, multiple staff and the resident’s family observed a decline in the resident’s condition, including increased confusion, combativeness, need for more assistance, and inability to feed himself. The family member reported noticing confusion at a care conference, being told the facility would follow up, and later being informed by a nurse that the sacral dressing had not been changed because the facility was waiting on supplies. The family continued to voice concerns about the resident’s decline and the worsening wound, and a nurse called the family to report that the wound looked worse and that the wound vac was off while waiting for the wound doctor. Progress notes documented increased drainage, foul odor, surrounding warmth, and edema of the sacral wound on multiple dates, as well as green/yellow drainage and increased tenderness on 1/6. The NP acknowledged being aware of concerns about bone in the sacral area and an abnormal CRP but stated she was not told the wound was hot to touch. On 1/8, the NP noted the resident did not look good and was not eating and ordered transfer to the hospital for altered mental status and possible infection. Hospital records from that date described septic shock from a necrotic sacral ulcer with osteomyelitis, bacteremia, and a large unstageable coccyx/sacral wound with exposed bone, necrotic tissue, circumferential undermining, erythema, and odor, along with additional unstageable or deep tissue injuries on the legs and ankle, confirming the deterioration that occurred while the resident was under the facility’s care.