F0684

D

Failure to Provide and Document Ordered Wound and Skin Treatments

Madison, Wisconsin Survey Completed on 02-25-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide ordered wound care and skin treatments and to document them according to policy for one resident. The facility’s wound care policy requires documentation of the date and time wound care is given, any refusals and reasons, and the signature and title of the person recording the data. The resident was admitted with multiple significant diagnoses, including type 2 diabetes with diabetic polyneuropathy, neutropenia, venous insufficiency, and obesity, and had multiple wounds on both feet and lower extremities. The physician’s orders included Calmoseptine ointment to the buttocks, groin, and folds every morning and at bedtime and after each toileting episode; bilateral high tubi grips on in the morning and off at bedtime for edema; and multiple specific wound care treatments to the left foot toes, left lower extremity, right foot, and right lower extremity, all to be completed twice daily and as needed.

On the morning shift of 1/18/26, the Medication Administration Record showed that these ordered treatments were not administered. There was no documentation that the Calmoseptine, tubi grips, or any of the ordered wound care treatments for the resident’s left foot toes, left lower extremity, right foot, or right lower extremity were provided during that shift. Interviews with multiple RNs and the DON confirmed that nurses are responsible for conducting wound treatments and dressing changes and that, when treatments are completed, they are expected to be signed out in the electronic health record, including documentation if a resident refuses treatment. No further documentation was provided to account for the missing wound care treatments on that morning shift.