F0686

D

Failure to Follow Wound Care Orders and Pressure-Relief Protocols for a Resident With Multiple Pressure Ulcers

Florissant, Missouri Survey Completed on 02-24-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to follow physician orders and its own wound management policy for a resident with multiple pressure injuries. The resident had severe cognitive impairment, paraplegia, diabetes, dependence in ADLs, and multiple pressure ulcers, including three stage 3 and one stage 4 ulcers that were not present on admission. The care plan and physician orders required specific wound treatments, use of a low air loss (LAL) mattress with settings checked every shift, regular skin assessments, and continuous use of bilateral protective boots for offloading. The facility’s wound management policy required that wound treatments be provided per physician orders, that dressings be changed when soiled or saturated, and that wound characteristics and care be documented.

Record review of the MAR showed numerous missed wound care treatments and failure to implement ordered offloading devices. For the left lateral ankle, ordered dressing changes every two days were missed two of three times; for the left lateral foot, daily dressing changes were missed five of 11 times. For the left medial buttock, barrier care ordered every shift was missed 18 of 45 opportunities. For the left buttock, BID dressing changes were missed 14 of 30 opportunities, and for the sacrum, BID dressing changes were missed 43 of 44 opportunities. The order for Prevalon protective boots to be on both feet at all times was missed 17 of 46 opportunities. A CNA reported being unaware of the order for protective boots, and observations on multiple days showed the resident in bed without the ordered boots in place.

Surveyor observations further documented failures in pressure-relief equipment management and wound care technique. The resident’s LAL mattress was repeatedly found set far above the resident’s documented weight, including settings at 350 lbs and later 490 lbs, despite the resident weighing 167 lbs and a wound physician’s prior recommendation to keep mattress settings at the patient’s weight. The mattress alarmed with “failure” messages on several occasions, and at one point was completely deflated while the resident remained in bed. The DON confirmed that the mattress settings were out of range and stated she would expect the mattress to be within the resident’s weight range. During wound care, the wound nurse did not clean the peri-wound area where barrier cream residue remained around the coccyx/sacrum wounds, and dressings were observed with heavy serosanguinous drainage and dates indicating they had not been changed over the weekend. The resident was also observed wearing a brief despite having a suprapubic catheter and buttock wounds, which the DON identified as contraindicated. The wound physician emphasized the importance of offloading, proper mattress settings, and protective boots, and noted that some CNAs did not understand the need to maintain mattress settings at the recommended weight levels.

Across multiple days and shifts, the resident was repeatedly observed lying on the left side without protective boots, with soiled or heavily drained dressings, and with the LAL mattress either malfunctioning, turned off, or set above the resident’s weight. Staff interviews confirmed gaps in awareness of orders and expectations for wound care and offloading. These actions and inactions collectively demonstrate the facility’s failure to provide ordered wound treatments, maintain appropriate pressure-relieving equipment settings, and consistently implement offloading interventions as required by physician orders and facility policy for this resident with advanced pressure injuries.