F0686

D

Failure to Provide and Document Ordered Pressure Ulcer Treatments for Two Residents

West Bloomfield, Michigan Survey Completed on 03-25-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure ordered pressure ulcer treatments were obtained, carried out as ordered, provided in a timely manner, and accurately documented for two residents with pressure injuries. One resident was admitted with a Stage 3 pressure ulcer and a surgical wound, and another was admitted with multiple pressure injuries including a Stage 4 and an unstageable ulcer. For the first resident, the MDS showed admission with a Stage 3 pressure ulcer on the right heel. The resident reported that wound care was supposed to be done every other day without exception, but stated that treatments were sometimes missed and that the leg wrap was often applied too tightly, causing pain. The resident specifically reported missing a scheduled treatment on a Friday and showed the surveyor a wrap that hurt.

Record review for this resident’s March Treatment Administration Records (TARs) showed multiple missed or undocumented wound treatments despite active physician orders. An order dated early in the month directed cleansing the right heel with normal saline, applying collagen, and covering with ABD pad and Kerlix wrap on Monday, Wednesday, and Friday. The TAR showed a blank, unexplained box for a Wednesday treatment and another blank for a Friday treatment when the order was discharged that same day. A subsequent order to cleanse with normal saline, apply collagen, and cover with border gauze on Monday, Wednesday, and Friday also showed missing treatments on a Wednesday and Friday, with only Saturday initialed as completed. Review of all March TAR entries confirmed that wound treatments were not documented as completed on the identified dates. The facility’s wound care nurse later acknowledged understanding the concern about missed treatments and stated that at least one treatment had been done but not documented. The nurse also confirmed that the correct treatment per current orders was a border foam dressing, not a Kerlix wrap, and that Kerlix had been used instead of the ordered border dressing.

The same resident also reported that on a later date the wound had worsened because the wrong dressing was used, stating that gauze was used instead of a bandage and that the wound bled more and appeared larger when the dressing was removed by the nurse and physician. The wound care nurse confirmed that the order called for a border foam dressing and not a Kerlix wrap, and that Kerlix was a rolled gauze wrap used for cushioning or compression rather than as the primary ordered dressing. The nurse further reported that the facility’s standard was to obtain wound photos every seven days, but no photo was taken because the camera battery had not been charged while the nurse was off work. The surveyor was unable to observe the resident’s scheduled wound care because it was completed earlier in the day than arranged, and the Nursing Home Administrator later accepted responsibility for the missed observation.

For the second resident, who was admitted with sepsis, atrial fibrillation, chronic kidney disease, and multiple pressure injuries, the MDS documented one Stage 4 and one unstageable pressure ulcer on admission. The admission nursing evaluation noted skin impairment to both heels and the sacrum, and an admission nurse’s note described wounds to both heels and an open wound to the coccyx, with measurements to be obtained per wound care protocol and dressings in place per hospital discharge orders. The hospital discharge paperwork contained detailed wound care orders for the left buttock, coccyx to right buttock, left heel, and right heel, all to be treated twice daily. However, the facility’s physician orders contained no wound treatment orders until several days after admission, and the TAR showed no documentation of wound care until the date after those orders were entered.

A skin check entry for this second resident dated several days after admission documented “No skin issues,” while a separate skin/wound entry later that same morning identified a left heel unstageable pressure ulcer and a coccyx Stage 4 pressure ulcer with specific measurements. During interview, the ADON, who had been the wound care coordinator, stated that the resident was admitted on a Saturday and that the admitting nurse did not enter the wound treatment orders from the hospital discharge paperwork. The ADON confirmed that wound care orders from the hospital should be entered the same way as medication orders and acknowledged that there was no documentation of wound care provided before the TAR entries began. The facility’s Skin Management policy required that residents admitted with skin impairment have appropriate interventions implemented, a physician’s order for treatment, and documentation of wound location, measurements, and characteristics, as well as photos unless refused, which contrasted with the gaps in orders, documentation, and initial assessments identified in the record review for this resident.