Failure to provide ordered wound care for a resident with hospice needs and multiple comorbidities. The resident had active orders for treatment of wounds on the hip and coccyx, but the TAR showed no documentation that the care was completed on two days after admission. An assigned LPN said she did not get around to the wound care and prioritized safety and med pass, while the wound care nurse said she delayed care because the resident was new. The DON confirmed the assigned LPN should have completed the treatment, and the unit manager said missed care should have been communicated to the next shift.
A resident with a stage 3 sacral pressure ulcer, malnutrition, and quadriplegia had repeated gaps in NPWT care, including times when the wound vac was not in place, supplies were unavailable, and clinic visits occurred without the vac or cannister. In another case, a resident with multiple neurologic and medical conditions had an inaccurate skin assessment that failed to document sacral redness and an open area, even though the wound provider identified a stage 3 sacral/coccyx pressure ulcer.
Wound care and skin assessment were not completed or documented appropriately for two residents. One resident with a stage 4 sacral PI was observed with a dressing dated several days earlier and without ordered heel offloading boots, despite physician orders for daily wound care and offloading. Another resident with dementia and severe PVD had a right lower leg skin tear/open area documented on weekly skin checks without adequate description, and heel concerns were not identified until WOC involvement, when the heel was later found to have eschar and necrosis.
Delayed wound care orders for a pressure ulcer. A resident admitted with multiple fractures had a sacral pressure ulcer and a skin tear documented on the admission assessment, but wound care orders were not obtained right away. The sacral wound later required multiple dressing orders, and the wound consult identified it as an unhealed Stage 3 PI. The DON stated staff did not obtain a wound care order when the pressure ulcer was identified on admission.
Failure to Address New Skin Breakdown: A resident with Alzheimer's, dementia, and prior stroke-related L-sided weakness was admitted for respite care and identified as moderate risk for skin breakdown, but the baseline care plan left skin breakdown blank. Although the admission skin assessment showed no breakdown, a later assessment on discharge documented redness and a small blister, with no charted notification to the MD or family despite the spouse reporting she informed the ADON before discharge.
Failure to provide ordered pressure ulcer prevention care occurred when a resident with Parkinson's disease, muscle weakness, a stage 4 sacral ulcer, and moderate cognitive impairment was ordered to wear soft boots in bed, but was repeatedly observed without them. Staff confirmed the resident had refused the boots, yet the refusal was not documented in the care plan or progress notes, and the order was not linked to the task list for staff documentation.
A resident with DMII, hemiplegia, incontinence, impaired mobility, anticoagulation therapy, and vascular disease developed a Stage IV sacral pressure ulcer that progressed with drainage, odor, slough, eschar, tunneling, and exposed bone, later requiring hospital transfer and treatment for osteomyelitis. The record showed delayed weekly skin sweeps, missed wound dressing changes, and gaps in documented wound care, while staff and the DON described a skin-check process that was not completed within the expected timeframe.
A resident with a right heel pressure injury, malnutrition, and dementia was found on a low air loss mattress set to static low pressure at 350 lbs, despite weighing about 111 lbs. Staff confirmed the setting was incorrect and stated the mattress should be set per the resident’s weight; the resident’s care plan included use of a low air loss mattress, but it did not specify weight-based settings.
A resident with severe dependence, contractures, and a worsening right hand wound had a soiled dressing observed on the knuckles, with no wound care care plan or interventions in the chart. The wound physician documented a DTI that progressed to a stage 3 wound and also a skin tear, but the facility had no active wound treatment orders in place until later, and staff stated wound care orders were verbally communicated rather than entered timely into the record.
A resident with a history of a buttock pressure ulcer had inconsistent documentation and wound care management. Admission skin assessment noted no impairment, yet later records identified a facility-acquired sacral wound and orders were written for daily wound treatment. During observation, an LPN said the resident only had foot wounds and was unaware of any buttock wound, while the resident and daughter stated the buttock wound existed before admission; the dressing on the right buttock revealed an open wound when removed.
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