F0684

D

Failure to Assess and Treat Non‑Pressure Wounds per Orders and Wound Consults

Chillicothe, Ohio Survey Completed on 02-26-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to document and treat non‑pressure skin areas according to physician and consultant orders, as well as failure to accurately implement updated wound care plans. For one resident with reduced mobility, severe protein‑calorie malnutrition, and a left heel open wound identified on admission, the admission assessment documented an open area with black scabbing and a wound evaluation measured the wound. A physician order was entered to cleanse the left heel wound, apply Medihoney, and cover with nonstick dressing, Kerlix, and ACE wrap daily. A wound consultant NP later assessed the wound as a diabetic foot ulcer, documented new measurements, and ordered a different treatment regimen using medical‑grade honey, abdominal dressing, rolled gauze, and daily changes, along with recommendations to float the heels in bed. Despite this, the physician orders were not updated to reflect the consultant’s plan, the Treatment Administration Record showed the original, incorrect treatment continued for several days, and observations on two separate dates found the resident in bed with heels not elevated.

Another resident admitted with type 2 diabetes with neuropathy, malnutrition, CKD stage 3, and a history of circulatory disease had vascular wounds to both lower extremities and additional unclear‑etiology wounds documented during a prior hospital stay, with specific orders to cleanse and dress bilateral lower extremity wounds every other day. The facility’s admission assessment only noted a skin tear and did not document or measure the bilateral lower extremity wounds. The plan of care referenced impaired skin integrity and treatments per physician/NP orders, but the TAR showed no wound treatments completed for the bilateral lower extremities for several days after admission. When a wound consultant NP later assessed a left shin venous ulcer and a right elbow skin tear and ordered specific treatments, the TAR again showed no documented treatments for the left shin venous ulcer or the right elbow skin tear for multiple days. A subsequent consult documented healing of the left shin ulcer and right elbow tear and identified a new right shin skin tear with a detailed treatment plan; however, the initial physician order for this new wound did not specify the site, and the TAR showed no treatments documented for the right shin wound until a later order explicitly identified the right shin.

A third resident admitted with cellulitis of the left lower limb, type 2 diabetes with neuropathy, CKD stage 3, venous insufficiency, and bilateral plantar diabetic foot ulcers had hospital discharge instructions for daily cleansing and dressing of bilateral lower extremity diabetic ulcers using normal saline, Xeroform, Adaptec calcium alginate, gauze, ABD, Kerlix, and ACE bandage. The admission assessment documented no skin impairments despite the reason for admission being cellulitis of the left foot. For several days after admission, there were no physician orders for bilateral diabetic foot ulcer treatments and no wound treatments documented on the TAR, and the medical record contained no measurements or assessments of the left and right lateral plantar diabetic foot ulcers. A progress note later documented a telephone order for daily treatments to the bilateral diabetic foot ulcers and to contact outside wound care, and physician orders were then entered for wound cleanser, Xeroform, and Kerlix to the bilateral diabetic foot ulcers. A wound overview completed later documented measurements for both plantar ulcers, confirming their presence and size during the period when they had not been assessed or treated per the hospital discharge instructions.

A fourth resident with acute hematogenous osteomyelitis, a left below‑knee amputation, type 2 diabetes, CKD, peripheral vascular disease, and a right lateral 5th toe diabetic ulcer had documented skin impairments of a left BKA surgical wound and right lateral 5th toe diabetic ulcer prior to a hospital transfer. After a hospital stay unrelated to the non‑pressure wounds, the resident was readmitted with discharge instructions that did not include non‑pressure wound care orders. The readmission assessment noted a vascular skin impairment and a surgical incision but did not specify locations or provide assessments and measurements. For several days following readmission, there were no physician orders for treatment of the left BKA surgical wound or the right lateral 5th toe diabetic ulcer, and the TAR showed no wound treatments completed. The medical record contained no assessments or measurements of these wounds during that period. Later, physician orders were entered for cleansing and leaving the right 5th toe ulcer open to air twice daily and for daily cleansing and sterile dressing of the left BKA incision, and a wound overview documented measurements for both wounds, indicating they had been present but not previously assessed or treated during the earlier days after readmission.