F0686

E

Missed Wound Treatments for Pressure Ulcers and Skin Failure

Desoto, Texas Survey Completed on 03-03-2026

Penalty

Fine: $15,940

Summary

The deficiency involves the facility’s failure to provide ordered pressure ulcer and wound care to multiple residents, as documented by missing treatments on wound care administration records and lack of corresponding progress notes. For one resident with severe cognitive impairment and multiple pressure ulcers on admission, including an unstageable left heel wound and several stage 4 pressure wounds on the left foot and toes, the wound care administration records for January and February showed numerous dates on which ordered treatments were not documented as completed. These missed treatments included care for the unstageable left heel wound and stage 4 pressure wounds of the left medial first toe, left fourth toe, and left distal medial foot across multiple days in January and February. Progress notes for this period contained no documentation of wound treatment, and later observation of the resident at a hospital showed wounds on the left heel, right buttocks, and left medial first toe covered with dry dressings.

Another resident, an older female with severe cognitive impairment and a diagnosis including open lesions, had a care plan identifying severely impaired skin integrity related to end-stage skin failure of the sacrum, with interventions including cleansing and application of specific dressings such as honey-coated absorbent dressings and later Dakin’s 1/4 strength–soaked gauze. The order summary report detailed daily and as-needed wound care orders for the sacral wound. However, the February wound care administration record showed no entries for multiple dates; instead, those dates were marked as “Missed,” indicating that the ordered wound care was not provided on those days. Progress notes for January and February also lacked documentation of wound treatment. During an observation in early March, the wound care nurse performed sacral wound care, and the old dressing was noted to be dated the previous day, demonstrating that treatments were being done at that time but not on the earlier missed dates.

A third resident, an older female with severe cognitive impairment, peripheral vascular disease, and a Kennedy terminal ulcer on the right ischium, had orders for cleansing the site and applying Dakin’s 1/4 strength–soaked gauze with a dry dressing on the day shift and as needed. The wound care administration record for February showed that on two specific dates the wound care entries were marked as “Missed,” indicating the ordered treatments were not provided. The resident’s care plan, revised in early March, noted the need for hospice care due to a terminal cerebrovascular condition and included interventions to administer treatments as ordered and monitor for skin breakdown. Observation with the wound care nurse showed that when wound care was performed, the old dressing on the sacrum was dated the previous day and the nurse followed the ordered cleansing and dressing procedure. In interviews, the wound care nurse stated he had not noticed wound care was being missed because he had not paid attention to the treatment administration records, and explained that he worked Monday through Thursday (later Monday through Friday per the DON), with floor nurses responsible for wound care on other days. The DON stated her expectation that all wounds were treated per physician orders and acknowledged that missing wound care could lead to increased risk of infection or worsening wounds.

Overall, across these three residents, the surveyors identified repeated failures to provide and document wound care as ordered, including for pressure ulcers, end-stage skin failure, and a Kennedy terminal ulcer. The wound care administration records showed multiple missed treatments, and there was no supporting documentation in progress notes for the relevant periods. Staff interviews confirmed that the wound care nurse relied on floor nurses to perform treatments when he was not present and that management reviewed treatment records in morning meetings but believed some wound care was missed while staff were learning a new system. The facility’s own wound care policy emphasized that effective prevention and treatment are based on consistently providing routine and individualized interventions, which contrasted with the documented pattern of missed wound care for these residents.

These failures placed residents at risk of developing new or worsening pressure ulcers, infection, and pain, as explicitly stated in the report.