F0686

G

Failure to Provide Timely and Appropriate Wound and Pressure Ulcer Care

Clearfield, Pennsylvania Survey Completed on 03-19-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide necessary treatment and services for an existing Stage 3/4 pressure ulcer for one resident and failure to follow physician orders in a timely manner for another resident. Facility policies required physician orders for wound care, detailed documentation of each treatment, weekly head-to-toe skin assessments, and adherence to negative pressure wound therapy (NPWT/wound vac) orders and manufacturer instructions, including frequent monitoring of the pump and changing dressings at least every 72 hours. The wound vac manufacturer’s instructions specified that the machine should be frequently checked to ensure it was on and delivering negative pressure and that dressings should not remain in place longer than 72 hours.

Resident 4, who was cognitively intact, dependent for care, frequently bowel incontinent, and diagnosed with paraplegia, had a Stage 4 pressure ulcer on the right buttock/ischium. Physician orders and a wound clinic consultation directed cleansing with soap and water, placement of white foam in tunnels, black foam to the wound bed, wound vac pressure at 125 mmHg, and dressing changes on specified days. Documentation showed the wound vac treatment was completed at the wound clinic on one date, and the resident later requested that wound vac changes be done in the morning instead of the evening. However, there was no documented evidence that the wound vac treatment was completed on the specified mornings following the resident’s requests. There was also no documentation that the wound vac was changed between several consecutive days, no evidence of routine checks to ensure the wound vac was functioning, and no RN wound assessment documented during that period, despite the wound vac not charging and ultimately going completely dead.

By the next wound clinic visit, the wound on Resident 4’s right buttock/ischium was documented as significantly worse, with markedly increased measurements, tunneling, undermining, and the presence of necrotic tissue, slough, and exudate requiring debridement. Interviews with wound clinic staff, LPNs, an RN, and the DON confirmed that the resident did not arrive at the clinic with a wound vac, that the wound vac had not been functioning properly, that there were necrotic areas and foul odor, that the wound was the worst it had ever been, and that no wound assessment had been completed during the time the wound vac was not working. Staff also confirmed that the wound clinic physician was not informed that the wound vac was not in use, that wet-to-dry dressings were being used instead, or that the wound condition had changed.

Resident 3 was admitted with an abrasion on the left calf, a friction area on the left buttock, and reddened heels requiring elevation. Physician orders included cleansing the left buttock wound with soap and water and applying zinc barrier cream every shift. The resident was cognitively intact, required extensive assistance, and had diagnoses including paraplegia and diabetes, and was care planned as being at risk for skin breakdown. A physician order for a wound care consultation was entered, and nursing documentation noted that the rounding provider updated orders, including the wound care consult. Subsequent clinical notes over several days documented moisture-associated skin damage to the buttocks with preventative skin measures in place.

Despite the physician’s order for a wound care consultation for Resident 3, there was no documented evidence that the resident was seen by a wound consultant from the date the consult was ordered until several weeks later, when a wound care consultation finally occurred and new treatment orders for bilateral buttocks were written. There was also no documentation that an appointment had been made for the consult or that the resident refused to be seen. The DON confirmed that Resident 3 was not seen by a wound consultant during that interval and that there was no documentation of scheduling or refusal. These omissions reflect the facility’s failure to follow physician orders in a timely manner for wound care consultation and treatment for Resident 3.