Failure to Follow Wound Care Orders and Document Pressure Ulcer Management
Penalty
Summary
The deficiency involves the facility’s failure to provide and document appropriate pressure ulcer and wound care for two residents admitted with existing pressure injuries. For one resident with advanced breast cancer, sepsis, cellulitis, and multiple unstageable pressure injuries, the Wound Care Specialist (WCS) ordered silver alginate dressings for a fungating chest wall mass and several pressure injuries. However, the resident’s Order Summary Report and Treatment Administration Record did not contain an order for calcium alginate or any as-needed wound dressing changes when dressings became soiled. The treatment nurse reported that this resident’s wound dressings were often soaked with blood and drainage at the start of the morning shift and were changed only once daily. Review of the resident’s Wound Care Forms for multiple dates showed no documented wound assessments, despite facility policies requiring detailed documentation of wound appearance, drainage, assessment data, and resident tolerance. For the second resident, who had cellulitis of the buttock, hidradenitis suppurativa, candidiasis, and multiple draining wounds, the Minimum Data Set showed intact cognition and total dependence on staff for ADLs. The physician’s orders directed daily wound care, including packing bilateral hips with NS-moistened kerlix and applying xeroform to the sacrum. The WCS later documented a plan of care specifying that dressings should be changed twice daily or as needed if soiled. Despite this, the resident’s Treatment Administration Record did not include any as-needed wound treatment orders, and the Order Summary Report as of early March only reflected daily wound dressing orders. The treatment nurse stated that this resident’s dressings were frequently wet with yellowish and pinkish drainage by the time he arrived in the morning, and he changed the dressings once daily. Across both residents, the facility did not follow its own policies and procedures for wound care and documentation. The Wound Care Forms for the second resident on multiple dates lacked any recorded wound assessments, and the DON acknowledged that the facility did not have complete documentation of wound assessments for either resident during wound care management as required by the Dressings, Dry/Clean, and Wound Care policies. The DON also stated that staff were not following the WCS treatment plans and that medications and treatments ordered by the WCS were not in place. These actions and omissions resulted in incomplete implementation of ordered wound treatments and inadequate documentation of wound status for both residents with pressure ulcers and other wounds.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.