F0658

D

Failure to Follow Wound Care Orders and Communicate Culture Results for Infected Stage 4 Sacral Ulcer

Saint Peters, Missouri Survey Completed on 02-20-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure wound care services met professional standards for a resident with a Stage 4 sacral pressure ulcer and known osteomyelitis. The resident was admitted with multiple serious conditions including multiple sclerosis, paraplegia, diabetes, and osteomyelitis of the vertebra, sacral, and sacrococcygeal regions, and had multiple pressure ulcers documented on the care plan. Facility policy required licensed nurses to perform admission, readmission, weekly, and as-needed skin assessments, notify the attending physician and IDT of wounds that worsened or did not respond to treatment, obtain and monitor labs and diagnostics as ordered, and document wound status and treatment effectiveness at least weekly. Despite these policies, the facility did not consistently follow physician orders, did not complete required weekly wound documentation, and did not ensure that diagnostic results and wound status were communicated to appropriate providers.

On 01/13/26, the wound care provider assessed the resident’s Stage 4 sacral ulcer, documented poor healing potential, moderate exudate, signs of clinical infection, and recommended continuing current treatment. On 01/20/26, the provider reassessed the sacral wound, noting it had increased in size, had moderate serosanguinous exudate exacerbated by infection, and again documented one or more signs of clinical infection. The provider performed fluorescence imaging, recommended adding mupirocin 2% topical twice daily, and ordered a deep wound culture. However, review of physician orders, the MAR, and the TAR from 01/20/26 through 01/29/26 showed no order for mupirocin and no documentation that mupirocin was applied. Interviews later revealed conflicting accounts: the regional nurse stated a nurse practitioner had ordered mupirocin on 01/20/26, while the NP denied ever seeing the wounds or ordering mupirocin. The regional wound nurse indicated that if the order was written in the wound provider’s note, the facility wound nurse should have checked the report the next day and followed through, but this did not occur.

A wound culture of the sacral tissue collected on 01/20/26 and reported on 01/23/26 identified multiple pathogens, listed first-line and alternative systemic antibiotic options, and included mupirocin 2% ointment as an additional option. A handwritten note on the report stated "will see during next rounds" with initials, but the culture results were not entered into the resident’s medical record between 01/21/26 and 01/30/26, and there was no documentation that the primary physician, hospice, or IDT were notified of the culture findings. The DON reported she could not find culture or biopsy results in the record, and the wound nurse stated she did not obtain the culture results until surveyors asked questions, at which point she found the wound provider’s notes in the electronic record. The hospice RN, who assumed wound care on 01/26/26 based on measurements and treatment orders provided by the facility LPN, was not informed that a culture or biopsy had been done and stated that, had the culture report been shared, hospice would have consulted their physician about starting antibiotics.

During the period from 01/21/26 through 01/30/26, there was no further documentation of the sacral wound in the resident’s medical record, despite facility policy requiring at least weekly wound documentation and documentation of changes in skin condition. The wound care provider did not return the week of 01/26/26 due to weather, and the LPN did not notify the primary physician or responsible party of the canceled visit or any change in wound status. The biopsy of the sacrum collected on 01/20/26, later reported on 02/04/26, confirmed acute and chronic osteomyelitis, but this result was not present in the facility record during the relevant period and was not communicated to hospice. On 01/30/26, an order for mupirocin 2% to the sacrum with daily dressing changes was finally entered, but the TAR showed the resident was already in the hospital on those dates. Hospital lab results from 01/30/26 documented markedly elevated WBC and neutrophil counts and an elevated lactate level consistent with sepsis, and the family reported the resident required ICU admission, IV antibiotics, and multiple surgeries for the infected sacral ulcer. Facility leadership, including the administrator and medical director, stated they would have expected all lab results, cultures, biopsies, and wound care provider orders to be reviewed, communicated, and followed, but this did not occur in this case.