F0686

D

Delayed Transcription and Implementation of Updated Wound Care Orders

Sugar Land, Texas Survey Completed on 02-13-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure that a resident with a pressure ulcer received necessary treatment and services consistent with professional standards of practice. The resident was an elderly female with multiple complex diagnoses, including hypoxic encephalopathy, cerebral infarction, emphysema, acute respiratory failure with hypoxia, pulmonary edema, type 2 diabetes mellitus, morbid obesity, dysphagia, hemiplegia and hemiparesis, seizures, intracranial hemorrhage, anemia, elevated white blood cell count, myocardial infarction, heart failure, pneumonitis due to aspiration, rhabdomyolysis, hyponatremia, gastrostomy, and hypothermia. Her admission MDS showed severely impaired cognition with a BIMS score of 3, dependence in toileting and personal hygiene, and functional impairments in upper and lower extremities. She was initially identified as having no pressure ulcers but at risk for development, and was care planned for pressure ulcer prevention with interventions such as barrier cream, turning and repositioning every two hours and as needed, and use of suspension devices to reduce pressure on heels and bony prominences.

Subsequently, a clinically unavoidable pressure injury form dated 01/25/26 documented a stage 2 coccyx blister. On 01/28/26, a wound treatment order was in place for the sacral area using calcium alginate with TRIAD cream, to be applied daily. On 01/29/26, the Wound Care Specialist NP assessed the sacral wound, identified as a sacral pressure injury, and issued a new written order for zinc plus collagen powder as the wound treatment. This new order was intended to be transcribed and carried out by facility staff. However, review of the resident’s February MAR and TAR showed that the zinc plus collagen powder order was not initiated until 02/04/26, and the completed order summary reflected that the calcium alginate order was not discontinued and the new collagen with TRIAD order not started until 02/03/26, indicating a delay in implementing the updated wound care regimen.

Interviews clarified the actions and inactions leading to the delay. The wound care LVN stated he discovered the sacral redness on 01/28/26, notified the family and NP, and received the initial calcium alginate order. He reported that the new wound care order from 01/29/26 was not transcribed the same day, citing internet issues and other obligations such as calling families about new orders, and acknowledged he did not see the new order until 02/03/26. The Wound Care Specialist NP confirmed she provided the zinc plus collagen powder order on 01/29/26 and expected it to be transcribed and implemented, and was unaware it had not been started until 02/04/26. The DON stated that the LVN was responsible for transcribing treatment orders and that the ADON shared an office with him and was responsible for ensuring all orders, including wound care orders, were transcribed in a timely manner, while the ADON reported she was not aware the new wound care orders had not been transcribed and that overseeing wound care orders had not been specifically assigned to her. Facility policies required that consulting practitioner orders be noted and transcribed to the medication or treatment administration record in a timely manner, which did not occur in this case.