F0686

G

Failure to Transcribe, Implement, and Consistently Provide Ordered Pressure Ulcer Care

Grand Rapids, Michigan Survey Completed on 03-05-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide adequate pressure ulcer care and to prevent worsening of existing pressure injuries for two residents. For one resident with metabolic encephalopathy, hospital discharge paperwork and a handwritten note from hospital staff documented existing skin issues, including a right hip wound and incontinence-associated dermatitis, with specific wound care instructions such as cleansing, Xeroform and foam dressings on a set schedule, frequent turning and repositioning, heel offloading, and use of barrier creams. These instructions were not transcribed into the facility’s physician orders, treatment records, or care plans upon admission. The admission skin assessment documented only a right hip surgical site and did not record any open wounds or refusals for skin assessment, and there were no sacral wound orders or treatments documented for several days after admission. The pressure ulcer care plan for the sacrum was not developed until two weeks after admission, and the incontinence and skin care plans did not reflect the resident’s need for frequent incontinence care or any refusals of care.

Subsequent assessments and documentation for this resident showed inconsistent and delayed recognition and treatment of a sacral pressure injury. A new sacral pressure ulcer was first documented days after admission as a Stage 3 pressure ulcer, with measurements and moderate drainage, and wound care orders were initiated the following day. A wound provider later assessed the sacral wound as an unstageable pressure ulcer, noted heavy drainage, and ordered daily dressing changes with Manuka dressing, an APM bed, heel protectors, offloading, and frequent incontinence changes. However, the provider’s daily dressing order was incorrectly entered as every other day, and the TAR showed missed or undocumented treatments, including no documented dressing change on a scheduled day and no PRN wound care orders. Staff interviews revealed that the resident was very hard to reposition, required two-person assistance, was incontinent, and did not refuse care, and CNA documentation showed no refusals of incontinence care. A CNA reported finding a large sacral dressing that was foul-smelling and urine-soaked, notifying an LPN twice, and observing that the dressing remained unchanged for many hours; another LPN later changed the dressing without cleansing the wound. The resident’s change in mental status and suspected sepsis from the coccyx wound were documented only shortly before transfer to the hospital, where the sacral ulcer was described as a large, foul-smelling, unstageable pressure sore with black eschar and sepsis secondary to the sacral decubitus ulcer.

For a second resident with a right heel pressure injury, the facility failed to provide consistent wound care as ordered, resulting in deterioration and infection of the heel wound. The pressure ulcer care plan identified a right heel pressure injury and called for wound care per physician orders and weekly skin evaluations, but wound provider notes over several months documented that dressings were grossly soiled, left in place far beyond the ordered change frequency, and not consistent with the prescribed products. The wound provider repeatedly noted missed dressing changes, wrong dressings, deterioration of the wound, strong odor, and concerns for cellulitis and infection, and ordered systemic and topical antibiotics and more frequent dressing changes. Review of physician orders and treatment records showed multiple missed and refused treatments across three months, with no corresponding progress notes or documentation of PRN wound care or re-attempts after refusals. Staff interviews indicated that some nurses, including agency staff, were unaware of the resident’s wound or dressing orders, that dressing changes were typically assigned to night shift, and that the resident did not usually refuse care, despite multiple refusals being recorded without supporting narrative documentation. These actions and omissions led to worsening of the resident’s unstageable right heel pressure injury and required antibiotic interventions for infection.

The facility’s internal nursing leadership acknowledged awareness of ongoing issues with wound care not being completed as ordered for multiple residents, including missed dressing changes, incomplete documentation, and lack of availability of ordered wound care products. The ADON, who managed wounds, reported not reviewing the first resident’s hospital discharge paperwork until after the wound had already worsened and acknowledged that wound orders from the hospital should have been entered on admission. She also reported discovering months earlier that other residents were not receiving ordered wound care and that she and the unit manager had been monitoring for missed treatments. The DON confirmed that there were no documented refusals of incontinence or wound care for the first resident and that she was aware of prior problems with wound care not being completed. The administrator reported that wound-related QAPI discussions had focused only on the number of wounds, not on missed or incomplete wound care, indicating that the documented failures in assessment, order transcription, treatment implementation, and monitoring directly contributed to the cited deficiencies in pressure ulcer care for both residents.