F0684

E

Failure to Assess, Document, and Care Plan Wounds and Orthotic Use for Multiple Residents

Hermitage, Missouri Survey Completed on 03-05-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to monitor, obtain, and document treatment orders and to care plan wounds and orthotic use for multiple residents, contrary to its wound care policy. One resident with vascular dementia and severe cognitive impairment sustained an unwitnessed fall in the special care unit dining area, resulting in a forehead laceration, right wrist sprain, closed head injury, and cervical sprain. The hospital discharge summary directed that the resident wear a right wrist splint until cleared by the physician and follow up with the primary physician. Upon return, nursing documentation noted the removable splint and Dermabond-closed laceration, but there was no immediate wound assessment; the first wound assessment was completed six days after the laceration occurred. The care plan was not updated to include the recent fall, laceration, or right wrist sprain, and there were no early physician orders to monitor the head laceration or the skin under the splint. Staff interviews revealed confusion about which arm required the splint, with some CNAs recalling the splint on the right arm and others stating it was always on the left, and observations showed the splint off and lying on the counter without documentation of refusal or monitoring.

Another resident with severe cognitive impairment, intracerebral hemorrhage, and chronic leg wounds had an active order to cleanse the right calf wound, apply skin prep, calcium alginate, and cover with border gauze daily and as needed. Medication administration records showed the treatment was not documented as completed on at least two days, and January progress notes contained no documentation related to the right calf wound. Multiple weekly skin assessments in January and February documented skin as intact with no treatment in place, despite the ongoing wound treatment order and a wound management report later identifying an ulcer on the right ankle/lower calf with slough and drainage. Facility records showed missing weekly skin assessments on some dates and no wound assessments for January. Observations of wound care revealed the resident had multiple open areas on the right lower leg, including two wounds on the outer calf and later a total of five shallow open areas, but the nurse performed a single treatment based on one wound order, split a calcium alginate dressing between two wounds, and applied a bordered dressing that did not fully cover one open area and allowed the adhesive border to contact the wound bed. Staff and the nurse practitioner stated that all open areas should be assessed, documented, and have individualized orders, and that adhesive borders should not be placed directly on wound beds.

A third resident with severe cognitive impairment, psychotic disorder, dementia, and total dependence for ADLs was care planned as at risk for skin impairment, with interventions including weekly licensed nurse skin checks and reporting any signs of skin breakdown to the charge nurse and physician. A weekly skin assessment documented intact skin with no issues, and there were no nurse progress notes for several days. However, observation showed the resident scratching the left forearm with long fingernails and having four scabbed areas with surrounding redness, including one large scabbed area and three smaller ones, uncovered and without visible ointment. Multiple CNAs reported that the areas began as a skin tear approximately one to two weeks earlier, initially treated with steri-strips, then covered with a bandage and later bordered gauze, and that additional open areas developed from adhesive or scratching. The DON stated not being aware of the areas until the date of surveyor observation and confirmed that nurses should document new skin tears in progress notes, notify the physician and family, and obtain treatment or monitoring orders, but there was no earlier documentation of the skin tear or monitoring in the record. The deficiency centers on the facility’s failure across these residents to consistently assess, document, obtain and follow treatment orders, and incorporate wounds and orthotic use into care plans as required by facility policy.