F0686

K

Failure to Provide Ordered Daily Wound Care Resulting in Infected Pressure Ulcer

Houston, Texas Survey Completed on 03-05-2026

Penalty

Fine: $24,920

Summary

The deficiency involves the facility’s failure to provide ordered daily wound care to a resident with multiple pressure ulcers, resulting in an infected left hip wound. The resident, a 75-year-old man, was admitted with severe protein-calorie malnutrition, metabolic encephalopathy, peripheral vascular disease, and existing pressure ulcers, including sacral and right heel ulcers and osteomyelitis of the right ankle and foot. On readmission from the hospital, he had multiple pressure injuries: unstageable pressure ulcers on both hips, a stage 4 ulcer on the left posterior shoulder, a stage 3 coccyx ulcer, an unstageable ulcer on the left medial lateral foot, and a DTPI on the left 5th toe. Physician orders dated 2/11/26 required that each wound be treated every day shift with normal saline, pat dry, and application of Santyl, calcium alginate, and border foam dressings, and that the DTPI on the 5th toe be treated with betadine and iota every day shift.

Despite these orders, the treatment administration record (TAR) showed wound care documented only on 2/22/26, with all wound care documentation left blank for 2/23/26, 2/24/26, and 2/25/26. Nursing staff interviews revealed inconsistent and uncorroborated accounts of whether wound care was actually performed on those days. RN A stated she last dressed the wounds on 2/23/26 and could not explain the lack of documentation; no other staff could confirm that wound care occurred that day. LVN E claimed she performed wound care on 2/24/26 but admitted she did not document it in the TAR, stating she could not find the resident’s name and did not seek assistance from other nurses. CNA and nurse interviews about wound care performed on 2/26/26 indicated that the dressings still bore RN A’s initials from the prior treatment and appeared unchanged for 2–3 days, with staff noting a bad odor and drainage from the left hip wound.

On 2/27/26, observations and interviews documented that the resident’s room had a strong foul odor, which staff attributed to his wounds. During wound care that day, the Wound Care Doctor found the right hip wound to be very dark with mostly eschar and moderate drainage, and described the left hip wound as unstageable, very smelly, and appearing infected, with purulent and serosanguinous drainage and a yellow-tinged exudate that suggested depth. The left hip wound measured larger than previously documented and was diagnosed as infected. The Wound Care Doctor stated that if the resident had received wound care on the missed days, it could have helped prevent the decline of the left hip wound, although he could not say the infection was unavoidable due to the resident’s comorbidities and poor nutrition. Hospice staff also stated that while the resident’s wounds were considered unavoidable due to his condition, having wounds that were not being treated constituted neglect and that infections were avoidable. These findings led surveyors to identify an Immediate Jeopardy situation related to failure to provide necessary pressure ulcer treatment and services as ordered.