F0658

E

Failure to Follow Wound Care Orders, LAL Mattress Parameters, and Insulin Pen Standards

Grant City, Missouri Survey Completed on 02-26-2026

Penalty

No penalty information released

Summary

The deficiency involves multiple failures to follow professional standards of practice and physician orders for wound care, low air loss (LAL) mattress use, and insulin administration. One resident with two stage 3 pressure ulcers on both buttocks had physician orders for licensed nursing staff to clean the wounds with wound cleanser, use skin prep to the peri-wound area, apply collagen powder, and cover with bordered gauze on specified days, as well as to apply a zinc spray to the peri-wound area with dressing changes and daily. During an observed dressing change, the RN removed intact dressings, cleansed the wounds, applied collagen powder, and covered them with bordered gauze, but did not apply the ordered skin prep spray or zinc spray to the peri-wound area. When questioned afterward, the RN stated they believed the sprays were only done with morning and night dressing changes and did not return to complete the ordered treatment. The resident reported that staff were supposed to check the dressings every day shift and apply spray, but that this was rarely done and that primarily one LPN applied the spray. The DON confirmed that the RN should have completed the entire ordered treatment, including the sprays, and that nursing staff should perform treatments as ordered and according to the schedule.

Another deficiency involved the use and management of a LAL mattress for a resident who was cognitively severely impaired, dependent on staff for most ADLs, always incontinent, and at risk for pressure ulcers. The resident’s care plan did not address the use of a LAL mattress, and the physician orders contained no order for a LAL mattress or its settings. Multiple observations over several days showed the resident either in bed or out of bed with the LAL mattress consistently set at 350 pounds. When interviewed, an LPN stated they did not know who was responsible for checking the LAL mattress settings and thought it might be housekeeping. The Administrator stated that if a resident was on hospice, hospice should monitor to ensure the LAL mattress was on the correct setting. The facility did not provide a policy for the Drive LAL mattress.

Additional deficiencies were identified in insulin administration practices for several residents with diabetes mellitus. For one resident who was cognitively intact and independent with ADLs, orders included blood sugar checks twice daily and Humalog insulin 12 units three times daily with meals. Observation showed the resident checked their own blood sugar and reported a value of 184 to an LPN. The Humalog pen used had no pharmacy label, no open date, and only a handwritten first name and dose on the lid. The LPN did not clean the pen port before attaching the needle, did not prime the pen with two units, and then dialed and administered 12 units. For another cognitively intact resident with diabetes, orders included blood sugar checks before meals and at bedtime and Humalog 8 units three times a day. Observation showed the LPN obtained a blood sugar of 116 and used a Humalog pen that lacked a proper label and open date, with only handwritten initials and dose on the lid. Again, the LPN did not clean the port or prime the pen before dialing and administering 8 units.

A further observation of insulin administration for another resident showed the same LPN preparing to administer 12 units of insulin from a pen that had no open date written on it. The LPN had already attached the needle and drawn up the dose without priming the pen or cleaning the port. In a subsequent interview, the LPN stated they believed priming was only necessary when the pen was first opened and described their procedure as simply screwing on the needle and dialing the required amount, without mentioning port cleaning. The LPN acknowledged that insulin pens should be dated when opened. The DON stated that insulin pens should be labeled with the resident’s name, not used if not dated or labeled, the port should be cleaned with alcohol before attaching the needle, and the pens should be primed with two units before each use. The facility did not provide a policy for the use of insulin pens, although existing policies required that physician orders be followed as written and that wound care procedures include applying prescribed medications to the wound or wound area if ordered.