F0684

D

Failure to Provide and Document Continuous Wound Care for Elbow Skin Tear

Pasadena, California Survey Completed on 03-23-2026

Penalty

No penalty information released

Summary

The facility failed to obtain and provide continuous wound treatment for a resident’s right elbow skin tear in accordance with physician orders and facility policy. The resident, who had severe cognitive impairment and was dependent for all ADLs, had a physician’s order dated 1/7/2026 for daily wound care to the right elbow skin tear, including cleansing with normal saline, patting dry, applying Xeroform, and covering with a dry dressing for 30 days. Review of the Treatment Administration Record (TAR) and progress notes showed that wound treatments were not documented as provided on 1/19/2026, 1/27/2026, and from 2/6/2026 to 2/14/2026. Treatment Nurse 1 confirmed that there were no initials on the TAR and no progress note documentation indicating that the ordered wound care was performed on those dates.

Further review revealed that there was no active treatment order for the right elbow wound between 2/6/2026 and 2/14/2026, despite the ongoing need for care. Registered Nurse 2 confirmed the absence of a treatment order during that period and stated that staff, including LVNs, treatment nurses, and RNs, are responsible for monitoring wound treatment, communicating with the physician, and clarifying continuation of wound care. The facility’s wound management policy, revised 11/1/2017, stated that residents with wounds are to receive necessary treatment and services to promote healing, prevent infection, and prevent new pressure ulcers, and that the attending physician will be notified promptly to advise on appropriate treatment. Staff interviews indicated that continuous treatment and documentation are necessary to assess wound progress and that if wound treatment is not documented, it is considered not to have occurred.