F0686

D

Failure to Follow and Document Ordered Pressure Ulcer Treatments

Greensburg, Pennsylvania Survey Completed on 02-04-2026

Penalty

No penalty information released

Summary

The facility failed to ensure that ordered pressure ulcer treatments were provided and documented for two residents with pressure injuries. For one resident, an admission change MDS dated December 30, 2026, showed the resident was cognitively intact, had a stage 4 pressure ulcer on admission, required staff assistance for daily care, and had a medical history including stroke. Physician orders dated January 6, 2026, directed that the left buttock wound be cleansed with wound cleanser, patted dry, packed with iodoform packing strip, and covered with a silicone border every dayshift. Review of the January 2026 Treatment Administration Record (TAR) showed no documented evidence that these treatments were completed as ordered on January 12 and January 18, 2026.

Subsequent physician orders for the same resident dated January 19, 2026, added application of zinc oxide paste to the peri-wound area while continuing cleansing, packing with iodoform, and covering with a silicone border every dayshift. Review of the January 2026 TAR again revealed no documented evidence that these updated treatments were completed as ordered on January 24 and January 25, 2026. The Director of Nursing confirmed on February 4, 2026, that there was no documented evidence that the resident’s wound treatments were completed on the identified dates.

For another resident, a quarterly MDS dated December 20, 2025, indicated the resident was cognitively intact, required staff assistance for daily care, had pressure ulcers, and had dementia. Skin and wound notes dated December 22, 2025, January 2, 2026, and January 9, 2026, documented wound care recommendations for right and left buttocks pressure ulcers: cleanse with wound cleanser or normal saline, apply zinc oxide paste to the wound base, secure with a dry dressing, and change daily and as needed. However, the January 2026 TAR showed that from January 1 through January 12, the wounds were documented as being left open to air with no dry dressing. A skin and wound note dated January 26, 2026, revised recommendations to cleanse with wound cleanser or normal saline, apply zinc oxide paste to the wound base, secure with bordered gauze, and change daily and as needed, but the January 2026 TAR documented the treatment as being completed three times a day from January 26 through February 3, 2026, rather than as ordered. The Assistant Director of Nursing confirmed there was no documented evidence that the wound care consultant’s recommendations were followed as ordered.