Failure to Provide Timely Wound Treatment for Existing Pressure Ulcers
Penalty
Summary
The deficiency involves the facility’s failure to provide timely and appropriate treatment and services for existing pressure ulcers for one resident. The resident reported being admitted from the hospital with sores on his bottom and stated he had not received a bath or shower and could not recall if his wounds had been addressed. The admission documentation (3008 Section T and initial skin assessment dated 02/27/2026) identified multiple pressure wounds on the sacrum, bilateral buttocks, and gluteal folds with specific measurements. Physician orders dated 02/27/2026 included daily monitoring of the sacral wound with documentation of dressing presence and status, surrounding skin condition, possible complications, and pain, as well as every-shift skin observations and Enhanced Barrier Precautions. However, there were no physician orders for actual wound care treatments such as cleansing method, type of dressing, or frequency of dressing changes. During a head-to-toe skin assessment on 03/03/2026 with the DON, the resident was observed wearing incontinence briefs with small areas of drainage and no wound dressings present for removal. The DON observed a large open area on the lower back approximately palm-sized with a dark black area in the center, and small open areas on the left and right lower buttocks/upper thigh areas. The DON and an RN then cleansed the wounds with normal saline and applied large bordered dressings. The RN later stated she recalled the resident arriving with dressings in place but could not explain why there were no dressings at the time of the observation, and confirmed she is the designated nurse assisting the wound NP on weekly wound rounds. The wound NP reported she makes rounds weekly, relies on the facility to email new admits or readmits to be seen, had received no communication requesting an earlier visit or guidance for this resident, and understood she was to see the resident on her normal weekly rounds. The facility’s wound treatment management policy requires that wound treatments be provided per physician orders and that, in the absence of treatment orders, the licensed nurse notify the physician to obtain them, which did not occur for this resident’s pressure 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.