F0656

E

Failure to Implement and Document Ordered Wound Care and Monitoring Over Multiple Months

Eunice, Louisiana Survey Completed on 03-25-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to implement and document physician-ordered wound care treatments and monitoring over a five-month period for a resident with Alzheimer’s disease and dementia. The resident was admitted with these diagnoses and subsequently developed multiple skin tears and a forehead laceration requiring daily cleansing with normal saline, application of triple antibiotic or Bacitracin ointment, and covered dressings until healed. Review of the November 2025 physician’s orders and Treatment Administration Record (TAR) showed an order for daily treatment of a right forearm skin tear, but there was no evidence on the TAR or MAR that this treatment was administered at all during that month.

Further review of the resident’s TARs and physician’s orders for December 2025, January 2026, February 2026, and March 2026 revealed multiple missed or undocumented treatments and monitoring. In December, daily treatments for a right elbow skin tear and a forehead laceration, including Bacitracin applications twice daily, lacked nurses’ initials or evidence of administration on several specified dates. In January, a daily treatment order for a skin tear between the fingers of the left hand was not documented as given on one date. In February, a daily treatment for a right pinky finger skin tear was not documented on one date. In March, daily treatments for skin tears to the right outer eye and right outer hand, as well as ordered q-shift monitoring of right knee swelling, were missing documentation on multiple shifts and dates. During interviews, the DON reviewed the records and confirmed there was no documented evidence that these ordered treatments and monitoring were completed on the identified dates.