F0684

D

Failure to Consistently Assess, Document, and Follow Up on Wounds and Skin Conditions

Lima, Ohio Survey Completed on 03-19-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide appropriate treatment and care according to orders, and to accurately and consistently assess and document skin conditions and wounds for multiple residents. For one resident with acute osteomyelitis, DM, PVD, CHF, and anemia, the medical record showed inconsistent documentation of a left heel wound, alternately described as a DM ulcer, a pressure ulcer, and a surgical site. The quarterly MDS did not document a surgical wound, despite other records indicating the presence of a left heel wound that had been debrided in the hospital and categorized as a surgical wound with serosanguinous drainage. A wound clinic note documented a left heel pressure ulcer with surgical site and sutures, but a later wound physician note contained no documentation that the facility addressed the left heel wound.

For this same resident, the facility had a physician order to cleanse the left heel and apply petroleum gauze and a silicone bordered dressing three times per week and as needed, and the wound nurse confirmed that these treatments were being performed. However, the wound nurse also stated that the facility had not measured the left heel wound from the time the resident was last seen at the wound clinic until the survey date, because they relied on the wound clinic to monitor the wound. The outpatient wound RN reported that the resident was last seen at the wound clinic in mid-January for evaluation of a left heel pressure ulcer with surgical site, and that the clinic had called the facility in early March to schedule a follow-up appointment but did not receive a return call. This resulted in a lack of ongoing wound measurements and a missed follow-up wound clinic appointment for the resident’s left heel wound.

Another resident, admitted with cerebral infarction with left hemiplegia, mood disorder, HTN, and epilepsy, had repeated documentation on shower sheets over multiple dates indicating redness under both breasts and in the groin area, with notes that the redness had worsened and that powder had not worked and had been present for months. Despite this, weekly skin assessments during the same period documented no skin issues. A weekly wound observation later identified fungal areas under both breasts and the belly button, but without measurements. Physician orders existed for miconazole cream under the breasts, later changed to antifungal powder, and additional orders were written for antifungal cream to the buttocks, oral Diflucan, and later Benadryl for itching. A wound NP note documented extensive fungal dermatitis under the breasts, in the groin, umbilicus, and buttocks, with erythema and odor, and provided specific measurements for several areas. The DON confirmed that weekly skin assessments in January and February did not document the rash and that no treatment was initiated for the groin or umbilical rash until late February, and also confirmed that Keflex ordered by Urgent Care for fungal infection of the skin and candidal intertrigo was not administered.

A third resident with DM, Down’s Syndrome, Hirschsprung’s disease, and morbid obesity had a non-pressure wound to the left sacrum documented by a wound NP as a trauma/injury with specific measurements and moderate serous exudate and slough, later described as a full-thickness trauma wound that underwent surgical debridement. A physician order directed daily cleansing of the sacral wound and application of calcium alginate with bordered gauze, and records showed treatments were completed as ordered. However, the medical record did not contain documentation of what caused the trauma or what type of trauma occurred to the sacrum. The MDS nurse confirmed that there was no documentation in the record to identify the cause or type of trauma to the sacral area. These combined findings for three residents demonstrate failures in ongoing assessment, timely and accurate documentation, and follow-through with ordered or recommended wound-related care and evaluations.