Failure to Implement and Update Wound Care Orders for Pressure Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to provide pressure ulcer care according to physician and wound nurse practitioner (NP) orders for a resident with an unstageable left heel pressure ulcer. The resident, an elderly female with severe cognitive impairment, type 2 diabetes, impaired mobility, and a history of left hip fracture, was admitted with a left heel pressure ulcer and was care planned to receive pressure injury care, including weekly wound measurements and monitoring for skin changes. The care plan also documented that she required maximum assistance for turning, repositioning, and transfers. Record review showed that the initial wound NP orders dated 02/17/2026 for the left heel pressure ulcer were to cleanse with soap and water, apply betadine, leave open to air, and change daily. These orders were entered into the eTAR, but wound care was not documented as provided until 02/18/2026, and there were missing signatures on multiple dates in February, indicating wound care was not completed on those days. Additionally, there was no wound care treatment order in the eTAR from 02/11/2026 through 02/17/2026. Subsequent NP wound evaluations on 03/03/2026 and 03/10/2026 changed the treatment orders to collagen hydrogel with silicone bordered dressing, and later to honey hydrogel sheet dressing with silicone bordered dressing, to be changed three times per week, but these updated orders were not entered into the eTAR. On 03/12/2026, observation of wound care revealed an RN performing treatment based on the outdated betadine and open-to-air order still present in the eTAR. The RN removed a loose bandage with brownish-red drainage, cleansed the wound, applied betadine, and left the wound open to air with the heel floated, consistent with the old order rather than the NP’s more recent recommendations. Interviews with the RN, DON, wound NP, corporate regional nurse, and administrator confirmed that the DON was responsible for updating wound care orders, that the NP had communicated updated orders and noted they were not implemented, and that the eTAR did not reflect the most current wound care orders. The facility’s wound care policy required verification of physician orders and documentation of wound care, but the orders were not timely updated and wound care was not consistently documented as provided.
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