F0684

D

Failure to Provide and Accurately Document Ordered Daily Wound Care

East Lansing, Michigan Survey Completed on 03-20-2026

Penalty

No penalty information released

Summary

Surveyors identified that ordered wound care was not completed as prescribed for a resident with multiple sclerosis, paraplegia, an indwelling urinary catheter, frequent bowel incontinence, and moisture associated skin damage (MASD). The resident’s MDS showed moderate cognitive impairment. A physician’s order dated 3/15/26 directed that the right thigh wound be cleansed with normal saline or wound cleanser, patted dry, skin prep applied to the peri-wound, collagen applied to the wound bed, and a border dressing applied, with the treatment to be done daily between 2:00 PM and 10:00 PM. A wound note on 3/16/26 documented a pink right thigh wound measuring 1 cm by 3 cm. On 3/20/26 at 12:02 PM, during incontinence care for loose stool that had leaked from the brief and soiled the bedding, surveyors observed a dressing on the back of the resident’s thigh dated 3/16/26, indicating that the dressing had not been changed since that date.

Review of the Treatment Administration Record (TAR) showed that the daily wound care was documented as completed on 3/17/26 and 3/19/26 by an LPN, and as refused on 3/18/26. The medical record contained no indication that the resident refused wound care on 3/16/26 or 3/19/26. The DON acknowledged that the TAR reflected wound care as completed on 3/17/26 and 3/19/26 and stated that the LPN might have clicked it off as completed or forgotten to document refusals, while attempts by both surveyors and facility leadership to contact the LPN for clarification were unsuccessful. The ADON, who served as the wound nurse, confirmed that the resident had MASD requiring daily wound care and later reported that the resident refused wound care when requested on 3/20/26. These observations and record reviews showed a failure to provide and accurately document the ordered daily wound care for the right thigh wound.