F0686

J

Failure to Implement Ordered Pressure Ulcer Treatments and Prevention Measures

Chillicothe, Ohio Survey Completed on 02-26-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide ordered pressure ulcer treatments and to implement effective pressure injury prevention and management for multiple residents, most notably a resident with paraplegia, a suprapubic catheter, an ostomy, and a known stage IV left ischial pressure ulcer with osteomyelitis on admission. Hospital records at admission documented orthopedic surgery’s recommendation for follow-up at a tertiary center for possible debridement and plastic surgery consultation for wound coverage/closure, but there was no evidence this recommendation was carried out. On admission, the resident’s skin impairment was documented only as “pressure” without location, assessment, or measurements, and the initial wound evaluation described a left buttock stage IV ulcer with minimal detail. A wound vac treatment was ordered but not documented as completed on multiple days, and the care plan initially lacked key interventions such as turning and repositioning, heel elevation, and a low air loss mattress, despite the resident’s dependence on staff for bed mobility and transfers.

Subsequent wound consultant nurse practitioner (WCNP) visits documented progressive worsening of the resident’s left ischial ulcer and the development and deterioration of additional pressure-related wounds, including a left heel unstageable ulcer, bilateral buttocks (gluteal dermatosis progressing to unstageable and then stage IV sacral involvement), and a right ischial unstageable ulcer. The WCNP repeatedly specified detailed treatment regimens (e.g., hydrogel, medical-grade honey, calcium alginate with silver, Santyl, Dakin’s solution-moistened gauze, zinc oxide, collagen, low air loss mattress, turning/repositioning, and heel floating), but the facility frequently failed to enter these orders correctly into the electronic record, omitted treatments entirely, or implemented incorrect treatments and frequencies. For example, there was no treatment order entered for the bilateral buttocks gluteal dermatosis after the 07/16/25 WCNP visit, no updated order for the left ischial ulcer at that time, and no treatment documented on the TAR for the buttocks on several days. Later, when Dakin’s solution and Santyl were ordered in the WCNP plan, the facility did not clarify the Dakin’s concentration, did not obtain Dakin’s or Santyl from the pharmacy for extended periods, and continued to provide incorrect or incomplete wound care. There was no documentation that the resident refused wound care or repositioning.

As the weeks progressed, wound measurements and descriptions documented by the WCNP showed increasing size, depth, undermining, slough, eschar, exposed deeper tissues (including muscle/fascia and subcutaneous tissue), malodor, and increased exudate in the left ischial, right ischial, and bilateral buttocks/sacral areas. Despite these changes and the resident’s total dependence for bed mobility, the MDS showed the resident was not on a turning/repositioning program, and the plan of care and interventions remained nonspecific or incomplete. Laboratory monitoring revealed elevated white blood cell (WBC) counts, with a WBC of 14.9 reported and acknowledged by the facility practitioner, and a subsequent WBC of 18.6 reported to the facility without documented notification to the practitioner or triage service. The resident ultimately requested transfer to the emergency room after being informed of the lab results and was hospitalized with osteomyelitis of the sacral stage IV pressure ulcer, requiring IV antibiotics and ongoing treatment for the left and right ischial ulcers. After a later hospital stay, the resident returned with documented wound care orders for sacral and bilateral ischial ulcers, but on readmission there were no corresponding treatment orders or documented treatments for these wounds on the first days back in the facility.

Additional deficiencies were identified for other residents. One resident, admitted at risk for pressure ulcer development and altered skin integrity, developed an in-house unstageable pressure ulcer when the facility failed to implement pressure ulcer prevention strategies. Another resident had failures in ensuring pressure ulcer prevention measures and care were in place, though this did not rise to the level of actual harm. Across these residents, the survey findings showed repeated failures to implement ordered wound treatments, to obtain and correctly use prescribed wound care products, to clarify incomplete orders (such as missing Dakin’s solution concentration), to consistently document and carry out preventive interventions like turning, repositioning, and heel protection, and to timely communicate abnormal laboratory findings related to wound status to medical providers.