F0684

D

Failure to Follow Wound Care Orders and Manage Wound Vac for Two Residents

Omaha, Nebraska Survey Completed on 03-12-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to follow physician orders for wound care and to provide ordered treatments consistently for two residents with significant vascular disease and surgical wounds. For one resident with chronic venous hypertension, venous insufficiency, and peripheral vascular disease, the admission record and skin assessment documented a venous ulcer on the right ankle with an order on the Treatment Administration Record to cleanse the right lateral ankle, apply Xeroform to the wound bed, cover with an ABD pad, and secure with kerlix, changing the dressing daily and as needed. During an observed wound care episode, an LPN cleansed the wound and applied Xeroform and kerlix secured with tape but did not apply the ordered ABD pad. The LPN confirmed that the ABD pad should have been used and that the dressing technique performed matched the order for the resident’s right toes rather than the right ankle.

For a second resident with Type 2 diabetes, peripheral vascular disease, and a recent surgical amputation of the left 3rd toe, multiple wound care orders were in place over time, including wound vac dressing changes to the left 3rd toe every three days and as needed, wound vac suction at 100 mmHg with constant suction, backup wet-to-dry dressings if the wound vac could not be used, and various betadine and gauze treatments to the left foot, toes, leg, thigh, and calf. Progress notes documented that the wound vac was not running due to a dead battery and missing charger, with no documentation of how long the wound vac had been off or what was done for the wound during that time. Later notes indicated the resident returned from dialysis with the wound vac machine off and no charge, the facility could not find the cord, and the wound vac was removed and replaced with a wet-to-dry dressing. Subsequent notes showed the wound vac was removed at an appointment and not reapplied, and that the resident at one point refused a wound vac dressing change, preferring a nurse who had previously performed it successfully.

Review of the MAR/TAR for this resident showed multiple wound-related orders were not completed or not documented as completed as ordered. The wound vac dressing order for one date was not completed, and a subsequent order for wound vac dressing changes every three days was entered as Monday/Wednesday/Friday instead of every three days and was marked refused on one date. The order to maintain wound vac suction at 100 mmHg with constant suction was not marked as completed on several specified shifts and was marked "no" on 23 of 45 shifts. The order to apply wet-to-dry dressings if the wound vac could not be used was not marked as completed, and orders for left leg and left thigh/calf wound care were not documented as completed on multiple ordered days. A provider note later documented that the left 3rd toe amputation site was macerated with a large amount of slough and that the resident reported the wound vac had only been changed weekly instead of three times per week, with new skin breakdown on the bottom of the foot attributed to that. The provider discontinued the wound vac and ordered daily betadine-moistened gauze dressings. The resident confirmed by telephone that only a few staff knew how to manage the wound vac or amputated toe dressing and reported multiple six-day stretches without dressing changes. An agency LPN reported no formal wound vac competency training, and the DON confirmed there was no wound vac policy or competencies and that the resident’s wound care orders were not completed as ordered.