F0684

E

Failure to Comprehensively Assess Wounds and Post-Fall Status for Multiple Residents

Racine, Wisconsin Survey Completed on 02-09-2026

Penalty

No penalty information released

Summary

The deficiency involves multiple failures to comprehensively assess residents and provide treatment and care in accordance with professional standards and facility policy. One resident with diarrhea related to IV antibiotics reported red, raw skin on the buttocks; nursing documentation later identified maceration in the gluteal fold but did not include measurements or tissue descriptors, and there was no documentation that a physician or NP was notified of this new skin breakdown. An antifungal powder was documented as being applied without a corresponding provider order, and the medicated powder—brought from a prior hospitalization—was being applied by a CNA rather than a licensed nurse. Subsequent skin documentation referenced “existing wounds” without specifying which wounds or describing them.

Another resident was admitted with cellulitis of the right lower limb, diabetes, diabetic foot ulcers, and chronic non‑pressure ulcers. The record showed multiple documented wounds on admission, but there was no assessment or descriptive documentation of the right lower leg cellulitis itself, despite progress notes stating the cellulitis was being monitored. A treatment order to cleanse with normal saline or wound cleanser and apply betadine daily did not specify the anatomical location where the treatment was to be applied. The wound nurse later stated that non‑pressure wounds such as cellulitis were expected to be assessed and documented by floor nurses or the Unit Manager, and that she had noticed and changed the nonspecific order only after her first wound assessment.

A third resident, cognitively intact and on Xarelto for atrial flutter, experienced an unwitnessed fall from bed, landing face down with the face resting on the metal base of an overbed table. Staff moved the table, rolled the resident, placed the resident on a mechanical lift sling, and transferred the resident to bed before contacting the NP. The resident had abrasions to the forehead, nose, and knee, a blood pressure of 86/57 with a pulse of 98, and altered mental status compared to prior documentation that the resident was alert and able to make needs known. EMS documentation indicated the resident was found in bed, was only oriented to person, had a weak pulse, and that the fall had occurred approximately 30 minutes before EMS arrival. Staff called a private ambulance service rather than 911, and the NP reported not being given any vital signs when notified of the fall.

Another resident with Alzheimer’s disease and on hospice had an unwitnessed fall, was found on the floor, and reported back pain rated 10/10. The facility’s neuro assessment flow sheet and the DCO’s interview confirmed that neurological checks after a fall were to be completed every 15 minutes for the first hour, every 30 minutes for the next hour, every hour for the next 2 hours, every 2 hours for the next 8 hours, every 4 hours for the next 12 hours, and then every shift for 48 hours. However, neurological assessments for this resident were only documented at six time points over approximately three hours, with gaps that did not follow the required frequency and no further neuro checks recorded after 1:20 PM.

A fifth resident developed a new skin wound that was not comprehensively assessed for etiology or documented with appropriate interventions to promote healing. Although an NP ordered a wound consult on the same day the wound was identified, the consult was not completed. This resident also had an unwitnessed fall while on blood‑thinning medication and was unable to communicate whether the head was struck; despite this, a thorough neurological assessment was not completed post‑fall, contrary to the facility’s falls policy and neuro‑check protocol. Collectively, these events show repeated failures to perform complete assessments, obtain and follow appropriate treatment orders, and adhere to established neuro‑assessment and falls procedures for residents with new wounds, cellulitis, and unwitnessed falls, including those on anticoagulants and with head injuries.