F0686

E

Failure to Provide and Document Ordered Pressure Ulcer Care and Weekly Skin Assessments

Cassville, Missouri Survey Completed on 02-24-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide pressure ulcer care and weekly skin and wound assessments in accordance with its own policies, physician orders, and accepted standards of practice for multiple residents with pressure injuries and other wounds. Facility policies required evidence‑based wound treatments per physician orders, weekly and as‑needed wound assessments with detailed measurements and descriptions, and documentation of each treatment or dressing status. Despite these requirements, treatment administration records (TARs), weekly skin observation tools, and nursing notes showed repeated gaps in documentation of ordered wound care and incomplete weekly skin assessments, with no corresponding documentation that care was refused or not provided.

One resident with diabetes, neuropathy, osteomyelitis, a stage 4 sacral pressure ulcer, and other wounds had numerous wound care orders for the coccyx, right ischium, scrotum, and right stump that were not documented as completed on many ordered days across January and February. For example, daily wound care orders to cleanse and dress the coccyx and right ischium, and daily hydrocolloid paste to the scrotum, showed large numbers of days with no TAR documentation, and there were no nursing notes indicating refusals or missed care. Observations showed undated dressings on the coccyx, right ischium, and right stump, and a nurse stated that the stump bandage appeared unchanged since several days earlier and acknowledged that wound care sometimes did not get completed and was not charted due to other work. The DON and wound provider were also observed removing undated dressings and reapplying new dressings without dating them.

Another resident with Arnold Chiari syndrome, spina bifida, paraplegia, and two stage 4 pressure ulcers to the sacrum and left ischium had daily wound care orders that were not documented on multiple days in January and February, including a period in February where documentation was missing on most ordered days after the treatment time was changed to afternoons. There were no progress notes indicating that wound care was refused or not provided. A cognitively intact resident with a stage 3 pressure ulcer on the posterior right thigh had an order for wound care three times weekly, yet TARs showed most ordered treatment days in January and February without documentation, and the bandage observed on the wound was dated several days prior; the DON again completed wound care without dating the new dressing. A resident with a stage 2 coccyx pressure ulcer had every‑other‑day and then nightly wound care orders with multiple undocumented treatment days, while weekly skin observation and wound physician notes documented the presence and progression of the coccyx wound. Across these residents, the facility’s own weekly skin assessment schedule and wound documentation policies were not consistently followed, as evidenced by missing weekly full‑body skin assessment details and repeated failures to document ordered wound treatments or dressing status.

A further resident, identified as at risk for skin breakdown with significant medical comorbidities, was also included in the facility’s census of affected residents, though the excerpted report section ends before detailing that resident’s specific wound orders and documentation gaps. Overall, the survey findings show that for at least five residents with pressure ulcers or other wounds, staff did not ensure weekly skin and wound assessments were completed and documented, did not consistently date dressings, and did not consistently document completion of ordered wound care on the TARs, despite facility policies and care plans requiring weekly assessments, measurement of wound progress, and documentation of each treatment or dressing status.