F0686

D

Failure to Provide Accurate Assessment and Consistent Treatment for Pressure Ulcers

Lebanon, Missouri Survey Completed on 02-10-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide pressure ulcer care in accordance with standards of practice, including timely and accurate skin and wound assessments, appropriate and updated treatment orders, and consistent implementation of ordered treatments for two residents with pressure injuries. For the first resident, admitted with dark, hard eschar on the left heel and a reddened buttock present on admission, the initial wound assessment documented these areas and listed interventions such as pressure-reducing devices, turning and repositioning, and heel protectors. However, the October physician orders did not include any specific treatment for the left heel wound, and the weekly skin assessment dated 10/23 documented intact skin with no issues, contradicting the earlier documentation of a left heel wound. Subsequent weekly skin assessments in November repeatedly documented intact skin with no issues to the feet, despite ongoing references in practitioner notes and other documentation to a left heel wound and buttock/coccyx wounds.

For this same resident, staff failed to complete weekly skin assessments on some weeks and did not document ongoing wound assessments for the left heel or coccyx/left buttock wounds in October and November. Nurse practitioner notes on 10/23 and 11/06 described a left heel wound with dry eschar and open areas on the right posterior thigh and left buttock, with plans for specific wound care, low air loss mattress, and wound care consults. Although orders were later entered for buttock and coccyx wound care, a low air loss bed, and wound care consult, the treatment administration records showed missed treatments on multiple dates, and progress notes did not consistently address the status of the wounds. The wound care company’s notes in December documented a large stage 2 coccyx pressure ulcer with specific treatment orders, but the facility’s physician orders did not reflect the use of calcium alginate as described by the wound care company. Additionally, new orders for bilateral heel treatments at the end of December were not carried out on the first two ordered days, and January documentation lacked progress notes regarding the left heel wound despite a dietician note referencing a left heel pressure ulcer.

Further, when the wound care company evaluated the resident in early February, they documented an unstageable left heel pressure wound that had been present for several weeks and a new stage 3 pressure ulcer on the right sole, with detailed treatment orders including hypochlorous acid, calcium alginate, Medi honey, bordered foam dressings, and Tubi grips. The facility’s February physician orders, however, were not updated to match these recommendations, instead continuing older orders that omitted calcium alginate, skin protectant, Medi honey, and Tubi grips. Interviews revealed additional concerns: an NA reported finding a dressing on the ball of the resident’s foot dated nearly two weeks earlier, suggesting dressing changes were not occurring as ordered, and the wound care company nurse practitioner stated that both foot wounds were debrided on the initial visit and that staff reported the left heel blister had been present for several months.

The second resident had multiple documented pressure ulcers, including a stage 3 sacral ulcer, an unstageable left heel deep tissue injury, a stage 3 left calf wound, and a stage 3 right foot ulcer. The wound care company provided detailed weekly progress notes in December and January, specifying wound measurements, staging, and treatment orders involving cleansing with hypochlorous acid, application of hydrofera blue, hydrogel, super absorbent pads, bordered gauze, and kerlix wraps, with daily dressing changes. Despite these detailed orders, the facility’s physician order sheets in December and January were not updated to reflect the wound care company’s current treatment plans. Instead, the POS continued to list older orders such as cleansing with wound cleanser and applying Santyl with wet-to-dry dressings, and later hydrofera blue combined with wet-to-dry dressings, which did not match the wound care company’s specified regimens.

For this resident, weekly skin assessments were incomplete or inconsistent, with at least one week in December lacking a documented skin assessment and other assessments vaguely referencing “existing non-foot skin issues” or foot/ankle issues without specific wound details, even though multiple pressure ulcers were present and being followed by the wound care company. Treatment administration records showed missed or incomplete treatments, including days when ordered treatments to the buttock, left heel, and left lower extremity were not documented as completed, and one instance where staff documented that treatment to the lower left extremity was not done due to running out of time. Wound care company notes on multiple visits also documented that incorrect dressings were in place upon arrival, such as calcium alginate instead of hydrofera blue or the use of wet-to-dry dressings instead of the ordered advanced dressings. Throughout this period, nursing progress notes provided minimal or nonspecific information about the resident’s multiple wounds, despite ongoing changes in wound status and treatment plans documented by the wound care company.

Overall, for both residents, the facility failed to ensure that wound care orders from the wound care company were promptly and accurately transcribed into the physician order sheets, failed to consistently perform and document weekly skin and wound assessments, and failed to administer and document wound treatments as ordered. Documentation often conflicted with prior assessments and specialist notes, with wounds being omitted from weekly skin assessments or described only in vague terms. Missed treatments, outdated or incorrect orders, and lack of detailed nursing progress notes regarding wound status contributed to the deficiency in providing appropriate pressure ulcer care and in preventing the development or worsening of pressure ulcers for these residents.