F0686

D

Failure to Initiate Timely Wound Care for Existing Pressure Ulcer

Painesville, Ohio Survey Completed on 03-17-2026

Penalty

No penalty information released

Summary

The facility failed to initiate timely wound care for a resident with a pressure sore, resulting in a period of three days without specific wound treatment orders after admission. The resident was admitted with diagnoses including cellulitis, prediabetes, and pressure sores, and a wound assessment documented on 09/05/25 identified an unstageable coccyx pressure ulcer measuring 2 cm by 2 cm with light serous exudate. Despite this documented pressure sore, no specific wound care orders were initiated or documented as completed until 09/08/25, when triad wound cream was ordered to be applied to the coccyx twice daily. The first wound nurse practitioner assessment on 09/09/25 documented the wound as significantly larger, measuring 11.5 cm by 11.2 cm with moderate serosanguinous exudate, and the wound NP recalled the sacral wound as very large and encompassing the bilateral buttocks, though she did not recall being informed of the initial smaller measurement and considered the possibility that the initial measurement was inaccurate. The DON and Administrator confirmed that no wound dressing orders were initiated for this resident until three days after admission, and this failure to promptly initiate wound care was cited as a deficiency under Complaint Number 2749003.