F0684

E

Failure to Provide Ordered NPWT and Wound Care for Two Residents

Monroeville, Pennsylvania Survey Completed on 02-27-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide prescribed wound treatments, including NPWT/wound vac therapy, and to follow physician orders for wound care for two residents. One resident with heart failure, diabetes, and a diabetic foot ulcer complicated by osteomyelitis was discharged from the hospital with debridement, antibiotic beads, and an order for a wound vac. Despite multiple clinical notes from physicians and wound NPs on several dates referencing that the left foot had antibiotic beads and a wound vac and requesting clarification or confirming that podiatry still recommended a wound vac, there was no active wound vac order in the facility record until nearly two weeks after admission. The resident’s care plan for diabetic ulcers did not include the need for a wound vac, and facility communications showed that a wound vac delivered to a sister facility was malfunctioning, not started, and then misplaced and later located, while the resident never actually received wound vac therapy.

For this same resident, the facility substituted wet-to-dry dressings in place of the wound vac but failed to consistently document that ordered wound care was provided. The TAR showed multiple dates and shifts with no documentation of wet-to-dry dressing changes and missing documentation for several other ordered wound treatments, including petrolatum gauze and various wound care orders to the left mid foot, left posterior thigh, right mid foot, right shin, and right medial lower leg. The resident reported never receiving a wound vac, being unhappy with wound care, and stated that he did not always receive wound care as scheduled and often had to request dressing changes. The resident also disputed documentation that he was pleased with wound progress and stated that while the wound did not deteriorate, there was negligible improvement.

The second resident had bacteremia, hypertension, and a history of stroke and was admitted with a PICO 14 NPWT dressing to the left femoral region per hospital discharge paperwork and physician orders. The plan of care for actual skin impairment did not include goals or interventions for the use of the PICO dressing. Progress notes and wound NP documentation confirmed that the PICO dressing and battery pack were in place and intact on multiple dates, with instructions that the dressing had a seven-day life and the battery pack a 14-day life, and that the dressing should be replaced at day seven or when saturated, conserving the battery pack until it turned off. However, the clinical record lacked documentation that the dressing portion was changed at the required seven-day intervals or that the battery pack was changed at 14 days, and a later note indicated the PICO battery was dead and the dressing was removed. The Nursing Home Administrator and DON confirmed that the facility failed to provide prescribed treatment and services related to wound care for these two residents.