F0684

D

Failure to Complete Ordered Daily Wound Care Treatments

Athens, Ohio Survey Completed on 03-09-2026

Penalty

No penalty information released

Summary

The facility failed to ensure that ordered non-pressure wound care treatments were completed as prescribed for one resident. The resident was admitted with type II diabetes and hidradenitis suppurativa, and an MDS assessment documented moisture associated skin damage (MASD). A care plan identified the resident as being at risk for skin impairment due to weakness, cognitive deficit, incontinence, impaired mobility, thin and fragile skin, falls, and autoimmune disease, with goals and interventions that included keeping the skin clean and dry, using lotion on dry but not broken skin, monitoring and documenting skin injuries, and following facility protocols for treatment. An order dated 11/18/25 directed daily wound care including cleansing with chlorhexidine wash, applying clindamycin gel to the wound, covering with an ABD pad, and applying nystatin powder to the peri-wound area; this order remained in effect until 12/19/25.

Record review of the treatment administration record for 12/2025 showed that this daily wound care was not completed on 12/11/25, 12/12/25, 12/16/25, and 12/18/25. A subsequent order dated 12/19/25 revised the daily treatment to include cleansing with chlorhexidine wash, applying clindamycin gel, applying calcium alginate, covering with an ABD pad, and applying nystatin powder to the peri-wound. The treatment administration record for 12/2025 showed missed treatments on 12/21/25, 12/25/25, 12/30/25, and 12/31/25, and the record for 01/2026 showed missed treatments on 01/03/26, 01/04/26, and 01/05/26. In an interview, the ADON confirmed that these treatments were not completed as ordered and stated there was no reason they should not have been completed and no additional documentation explaining the omissions. This deficiency was investigated under Complaint Number 2722441.