Failure to Implement Wound Consultant’s Recommendation for Wound Vac Settings
Penalty
Summary
Surveyors identified a deficiency in which the facility failed to ensure that wound consultant recommendations were reviewed with and incorporated into the attending physician’s orders for a resident. The resident’s annual MDS assessment dated February 24, 2026, documented that the resident was cognitively intact and had a stage 4 pressure ulcer on the right hip. Physician’s orders dated March 10, 2026, directed staff to clean the right hip wound and surrounding tissue with soap and warm water, rinse with saline, and apply a wound vac, ensuring black foam was placed into the tunneling, with dressing changes scheduled for Monday, Wednesday, and Friday, and suction set at 120 mmHg. A wound consultant note dated March 20, 2026, documented that the same resident’s stage 4 right hip pressure ulcer required a change in wound vac suction from 120 mmHg to 150 mmHg. Review of the resident’s March 2026 Treatment Administration Record showed that, as of March 31, 2026, the recommended change in wound vac suction had not been initiated. In an interview on March 31, 2026, at 12:25 p.m., the Director of Nursing confirmed that the wound care recommendations made by the wound care clinic on March 20, 2026, had not been updated in the resident’s clinical record as of that date, resulting in the failure to meet professional standards of nursing services as required by state regulations.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.