F0686

E

Failure to Provide Ordered Wound Care, Complete Transfer Skin Assessment, and Obtain Order for Wedge Pillow

Burbank, California Survey Completed on 02-03-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide pressure ulcer care consistent with physician orders and facility policy for a cognitively impaired resident with existing pressure injuries. The resident was admitted with metabolic encephalopathy, dementia, and pressure ulcers to the sacral area and left heel, and was documented as severely impaired in decision-making, fully dependent for ADLs, and always incontinent of bowel and bladder. Physician orders dated 7/19/2025 directed specific daily wound care for left heel and sacrococcyx deep tissue injuries, and subsequent orders on 11/11/2025, 12/17/2025, and 1/20/2026 specified detailed daily treatments for sacrococcyx stage 3 and later stage 4 pressure injuries, including cleansing solutions, topical agents, and dressings. Review of the Treatment Administration Records (TARs) from August 2025 through January 2026 showed multiple dates on which the ordered treatments were left blank, including 8/3/2025, 11/25/2025, 12/24/2025, 1/20/2026, and 1/27/2026.

Interviews with the MDS nurse, RN supervisor, and other nursing staff confirmed that blank entries on the TAR indicated the treatment nurse did not sign for and therefore did not perform the ordered wound care. Staff acknowledged that if the treatment was not done, the pressure ulcer could worsen. The facility’s wound care policy required verification of a physician’s order, performance of the ordered wound care, and documentation of the type of wound care given, the date and time, the resident’s position, and the name and title of the person performing the care. The RN supervisor stated that if treatment is not done, the treatment nurse must document the reason, such as resident refusal or being too busy and endorsing the task to other staff, but such documentation was not present for the missed treatments.

The deficiency also includes the facility’s failure to perform and document a complete head-to-toe skin assessment prior to the resident’s transfer to a general acute care hospital. On the transfer date, the resident’s Interact Assessment Form noted generalized weakness and decline in ADLs, and the Resident Transfer Record documented a sacrococcyx stage 3 pressure ulcer. RN 1 stated that for any transfer, a complete head-to-toe skin assessment should be done and documented on the transfer form and reported to the receiving hospital. RN 2 reported that, at the DON’s direction, she completed the Discharge Summary Report and Resident Transfer Record but only looked at the sacral area and did not perform a full body skin assessment, and therefore could not say whether the resident had rashes elsewhere. The facility’s Transfer/Discharge policy required a complete body check when possible, with findings documented, and the Prevention of Pressure Injuries policy required comprehensive skin assessments on admission, with each risk assessment, and prior to discharge.

Additionally, the facility failed to obtain a physician order for the use of a wedge pillow for this resident. During observation, a wedge pillow was seen on the resident’s left side. The treatment nurse stated the wedge pillow was used to keep the sacral area off the bed to prevent worsening of the pressure ulcer. Review of the physician orders showed no order for the wedge pillow, and both RN 1 and the treatment nurse acknowledged that a physician order was required before the resident could use a wedge pillow and that the DON or RN supervisor should have obtained such an order. The facility’s policies on pressure ulcers and prevention of pressure injuries specified that the physician orders pertinent wound treatments, including pressure reduction surfaces, and that medical devices should be selected with consideration to minimizing tissue damage, reinforcing the need for an order for this device.