F0684

G

Failure to Implement Wound MD and MD Orders, Monitor Change of Condition, and Provide Ordered Wound Care

Jackson, California Survey Completed on 03-10-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide necessary care and services and to follow professional standards in managing a resident’s worsening right lower leg venous ulcer and associated change in condition. The resident had a history of a non‑pressure chronic ulcer of the right lower leg, cellulitis, and type 2 diabetes, with severe cognitive impairment and a responsible party designated for decision‑making. Weekly skin assessments initially documented the wound as improving, but a later assessment described the wound as worse, with 100% slough/necrotic tissue and heavy drainage. During wound rounds on that date, the wound doctor (WD) observed the deterioration, noted the resident was in excruciating pain despite pre‑medication, and verbally recommended hospital admission for operative debridement above and below a possible leg amputation. The WD communicated this recommendation to the medical director (MD) and the wound nurse (WN), and the MD agreed that the resident needed a higher level of care and a vascular surgery evaluation.

Despite this, the facility did not timely implement the WD’s recommendation or the MD’s verbal order. The MD stated he gave a verbal order on the same date for the resident to be seen by a vascular surgeon and expected it to be carried out within 24 hours. However, the vascular surgery referral order was not entered into the medical record until five days later, and the consultation was not arranged before the resident was ultimately transferred to the hospital. The DON confirmed that the WN did not follow the facility’s policy requiring verbal orders to be recorded immediately and acknowledged that the order for vascular consultation was delayed. The WN also documented the WD’s assessment and recommendation as a progress note several days after the event without labeling it as a late entry, and the DON stated this late, unlabeled documentation could cause confusion and was not acceptable practice. The responsible party reported never refusing hospital transfer or raising cost concerns, and described the resident’s rapid cognitive decline and severe leg pain during this period.

The facility also failed to initiate and complete required monitoring and wound treatments after the change in condition was identified. The WN and DON both stated that the resident’s worsening wound and severe pain on the date of the WD’s assessment constituted a change of condition that should have triggered 72‑hour monitoring with vital signs and pain assessments every shift. Review of progress notes and the SBAR form showed that this monitoring was not initiated on the date of the change and was not completed every shift for 72 hours. The DON confirmed that vital signs and pain scores were not documented each shift following the change in condition. In addition, the Treatment Administration Record showed multiple missed Dakin’s solution treatments to the right lower leg venous ulcer on several days, and the WD reported that, on weekly visits, the dressings were dry, hard to remove, and stuck to the wound, leading him to question whether daily dressing changes were being performed as ordered. The DON verified the missed treatments and stated this created a risk of wound deterioration. Ultimately, the resident was sent to the hospital with confusion, hypotension, tachypnea, and laboratory evidence of sepsis, was diagnosed with septic shock related to right lower extremity cellulitis and necrotizing fasciitis, and died from cardiopulmonary arrest, septic shock, and necrotizing fasciitis of the right leg.