F0686

G

Failure to Timely Assess and Treat New Pressure Ulcer and Maintain Aseptic Wound Care Technique

Dover, Ohio Survey Completed on 02-02-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to comprehensively assess and promptly obtain treatment orders for a newly developed, in-house acquired pressure ulcer, resulting in further decline of the wound. The resident involved had multiple diagnoses including diabetes, diabetic neuropathy, hypertension, atherosclerotic heart disease, repeated falls, altered mental status, and a history of a left buttock Stage III pressure ulcer. The care plan identified the resident as needing assistance with ADLs due to decreased mobility and as being at risk for skin breakdown related to decreased mobility, diabetes, and incontinence, with interventions such as turning and repositioning, staff skin checks, toileting assistance, and appropriate diet. A Braden Scale assessment documented the resident as at risk for pressure injuries, and a quarterly MDS showed moderately impaired cognition and the need for assistance with mobility, but no pressure injuries at that time.

On 12/12/25, a Weekly Skin Observation note documented a new reddened, hard area on the buttock measuring 0.5 cm, and a progress note the same day described a small open area on the buttock that was hard and painful to touch. The area was cleaned and covered with a bordered foam dressing, and it was reported to the NP and wound team, but no treatment order was written at that time. There was no further documentation of a buttock pressure ulcer or any ordered or completed treatments until 12/15/25, when a physician order was finally obtained for cleansing, topical antibiotic, dressing changes, and systemic antibiotics, and the location was documented as the left gluteal fold rather than the right buttock. The DON and the former wound nurse later acknowledged that the original documentation of the wound as being on the right buttock was incorrect and that the wound had always been on the left buttock, and the DON verified that no treatment orders or interventions were put in place for three days after the wound was first identified.

Subsequent wound care NP notes documented that the buttock wound progressed to an unstageable ulcer and then a Stage III pressure ulcer, with measurements showing a significantly larger wound than initially described, the presence of slough, and later undermining. Orders for specific wound treatments, including Anasept gel, calcium alginate, silicone bordered foam dressings, Mesalt, and antibiotics, were written over time, but there were transcription errors and delays in initiating some NP orders. The DON confirmed that the NP’s 12/18/25 order for Anasept gel and moist gauze was not initiated until 12/23/25 and that the order for a silicone bordered foam dressing was incorrectly transcribed as a dry sterile dressing. A wound culture was obtained, but the facility never received or followed up on the results. During a later observation, the resident’s buttock wound was found without a dressing in place after the resident reported that dressings frequently fell off and were not always replaced when she requested. During the observed dressing change, the RN failed to prepare a clean, dry work area as required by policy, placed clean supplies and scissors on a visibly soiled overbed table, and used scissors that had been placed directly on the dirty surface to cut the dressing before applying it to the wound, contrary to the facility’s wound and skin care procedures.