F0684

G

Failure to Identify and Provide Ongoing Wound Care for Lower Extremity Ulcers

Plainfield, Indiana Survey Completed on 03-11-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to identify, assess, and provide ordered wound care services for a resident admitted with lower extremity wounds, resulting in prolonged periods without appropriate treatment and incomplete documentation. The resident was admitted from a hospital with documented deep tissue injuries to both lower extremities and was discharged with large bandages on her legs. The admission nursing skin assessment noted bruises, edema, weeping areas on both lower extremities, and other skin issues, but early NP and PA visit notes on 1/9 and 1/12 documented no wounds. A skin assessment on 1/12 recorded open areas on the front of both lower legs but lacked any detailed wound description or measurements. Despite the presence of dressings, the NP on 1/13 documented that dressings were present but did not observe the wounds, and the care plan initiated on 1/14 addressed only potential pressure ulcer development, with no care plan or interventions for non‑pressure wounds.

From admission through 1/20, the record shows inconsistent and incomplete skin assessments and a lack of timely wound care orders. Daily skilled nursing notes from 1/16 through 1/22 repeatedly indicated no change in skin integrity, and skin assessments were not completed or documented on some days. The NP note on 1/20 recorded that the resident reported her anterior bilateral leg bandages had not been changed since the hospital and that the left leg wound had drainage, yet the medical record contained no wound care orders from admission until 1/21. When wound care orders were finally entered on 1/21 for both legs, they were discontinued on 1/23 and replaced with new orders, including evening‑shift dressing changes, but the record still lacked detailed wound assessments, including measurements and descriptions, and lacked documentation of treatment or antibiotics when cellulitis was diagnosed on 1/23. Weekly skin assessments were signed on the TAR, but the underlying documentation again noted open areas on both lower legs without measurements or full descriptions, and NP notes continued to reference intact dressings and daily dressing changes without assessing the wounds beneath.

As the resident’s condition progressed, documentation remained incomplete and inconsistent with the facility’s wound management policy. On 1/29, the NP documented a quarter‑sized ulcer on the right shin and a large ulcer with slough and eschar on the left lower leg, noted heavy edema, and ordered Santyl and Medihoney, as well as a referral to a consultant wound care service. Subsequent skilled nursing notes on 1/30, 1/31, and 2/3 still indicated no changes in skin integrity while referencing dressing changes per orders. An antibiotic (doxycycline) was ordered on 2/4 for left lower extremity cellulitis, and an NP note on 2/5 mentioned cellulitis and extreme edema but did not document wound assessment or interventions. On 2/11, the facility wound nurse documented only one venous stasis ulcer on the right lower extremity, while the consultant wound NP identified four abscess wounds on both legs with specific measurements. Later that day, the resident experienced extremely low blood pressure and difficulty breathing, was transferred to the hospital ICU, and was diagnosed with septic shock secondary to her wounds, multiple lower extremity wounds, cellulitis, and significant hypotension. Interviews with the former NP, LPNs, the wound nurse, and the Regional Nurse confirmed that wounds were not consistently assessed, that the NP did not always look at wounds, that wound documentation was poor, and that required weekly skin assessments and admission wound documentation with measurements and photos were not reliably completed, contrary to the facility’s wound management policy.

The facility’s own policy required thorough skin assessments on admission, weekly, and as needed, with measurement and documentation of any new wounds and immediate implementation of physician‑ordered treatments, as well as notification of the attending physician and IDT for new wounds or pressure injuries. However, the record for this resident lacked timely wound care orders from admission, lacked consistent and complete wound assessments (including measurements and descriptions), and lacked appropriate care planning for non‑pressure wounds. Staff interviews corroborated that the NP did not always assess wounds, that documentation often “fell through the cracks,” and that the wound nurse was initially advised the resident had no wounds on admission despite hospital documentation and the admission skin assessment indicating otherwise. These actions and omissions led to a failure to provide necessary wound treatment and services to promote healing and prevent worsening of the resident’s lower extremity wounds.