Failure to Complete Ordered Heel Wound Care and Weekly Skin Assessments
Penalty
Summary
The deficiency involves the facility’s failure to complete weekly skin assessments and ordered wound treatments for a bedbound resident with a left heel wound. The resident, admitted with multiple diagnoses including morbid obesity, schizoaffective disorder, chronic pain syndrome, osteoarthritis, and major depression, had moderate cognitive impairment and required staff assistance for ADLs. Facility records showed that from the time the heel wound was identified on 12/18/25 through 03/23/26, only two weekly skin assessments were documented, on 02/03/26 and 03/17/26, despite facility policy requiring weekly assessments with each risk assessment. The resident’s care plan identified her as at risk for skin breakdown due to incontinence, decreased mobility, impaired cognition, and obesity, and noted she was resistive to care and turning and repositioning, with interventions including completion and monitoring of skin treatments per physician orders. Review of the physician’s order dated 03/06/26 showed a nightly and as-needed wound care regimen for the left heel, including cleansing, drying, applying collagen, and covering with a border foam dressing. The TAR from 12/18/25 through 03/24/26 showed the left heel wound treatment documented as completed, including entries by multiple LPNs on 03/21/26, 03/22/26, and 03/23/26. However, on 03/24/26, observation of the resident’s left heel with an LPN and the DON revealed the dressing was dated 03/22/26 and was two days old. The DON confirmed that the night-shift LPN who worked on 03/21/26 had dated the dressing 03/22/26 and signed the TAR on 03/21/26. Another LPN stated he did not know the resident had a heel treatment, verified he had not completed the treatment on 03/22/26, and stated he was not falsifying documentation when signing it off. The DON further verified that only two weekly skin assessments had been completed during the review period, contrary to facility policy and expectations.
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