Two residents with multiple pressure ulcers and other wounds did not consistently receive and/or have documented the ordered wound treatments, and proper infection control was not maintained during wound care. For one resident with severe cognitive impairment and multiple unstageable pressure ulcers, physician-ordered treatments to the heel, coccyx, sacrum, and buttocks were repeatedly not signed out as completed on the TAR over many days, despite a care plan directing staff to administer treatments as ordered. For another resident with diabetes, renal insufficiency, spina bifida, an indwelling catheter, and advanced pressure ulcers, an LPN failed to disinfect scissors between dirty and clean tasks, did not change gloves between cleansing a wound and handling new dressings, and removed a dressing from a necrotic foot wound without cleansing or redressing it during the observation. Review of orders and TARs for this resident also showed multiple missing entries for ordered treatments to the heel, foot, and leg/thigh wounds, contrary to facility policies requiring accurate administration and documentation of topical treatments and wound care.
A resident with severe cognitive impairment, hip fracture, and malnutrition was identified as at risk for pressure sores, but when the Braden score declined from low to moderate risk, the facility did not document additional targeted interventions to prevent pressure ulcers. The care plan contained only general skin care measures, and the clinical record lacked evidence of timely, risk-based prevention despite the increased risk level. The resident subsequently developed a left heel pressure area that progressed to an unstageable ulcer with black eschar and increasing size. The DON later stated there was no established procedure for pressure ulcer prevention and treatment during this period, contrary to NPIAP guidance on structured risk assessment and pressure offloading, including for the heels.
A resident with severe cognitive impairment and a right heel pressure injury did not receive consistent pressure ulcer care and offloading. The care plan referenced a cushion boot and the TAR included nightly Betadine treatment, but documentation of treatments and wound measurements was incomplete and inconsistent across skin assessments, Skin Issues forms, and progress notes. Observations showed the resident repeatedly in a w/c wearing only socks with feet on the footrests, while heel protectors were left on a recliner or not applied in bed, despite a cue card indicating a pressure boot. Staff interviews revealed uncertainty about whether and when to use the heel protector, lack of clear directions in the care plan and wall picture system, and absence of the device on the TAR, contrary to facility policies requiring documented use of pressure-relieving devices and regular wound assessment.
Failure to monitor and document a coccyx pressure area led to a deficiency for a resident with Alzheimer’s disease, DM, HTN, and severe cognitive impairment. Skin checks were missed or lacked documentation, the physician was not timely notified of the new open area, and the record showed no documented treatment for the wound for a period of time. The resident later had an ongoing coccyx pressure ulcer with orders for wound care and nutritional support.
Failure to assess, document, and treat pressure ulcers led to inconsistent wound care for two residents. One resident with intact cognition and multiple risk factors had heel wounds repeatedly described as scabs or non-pressure areas, despite ongoing soreness and later wound center findings of bilateral heel pressure ulcers that were debrided and labeled Stage 3. Another resident’s buttock wounds were not documented on the facility’s admission skin assessment, and later records showed unstageable pressure wounds and a Stage 3 wound with incomplete follow-up and inconsistent nursing documentation.
A resident with severe cognitive impairment and total care needs had a right heel pressure ulcer, but ordered wound care and weekly documentation were not consistently completed as directed. The chart showed Betadine and Mepilex were given on bath days, a weekly wound measurement was missing, and the wound later deteriorated after a period of improvement. Staff interviews confirmed the treatment process and that the DON expected orders to be followed as written.
A resident with paraplegia, neurogenic bowel and bladder, and a history of a recurrent stage 4 pressure wound was care planned for impaired skin integrity, but weekly skin and non‑pressure wound assessments failed to identify and document an open wound to the gluteal fold that was later described in a progress note as a granulating wound with drainage. The RN responsible for the weekly wound assessment acknowledged performing the assessment on a different day than recorded and focusing only on known areas of concern rather than completing a full head‑to‑toe skin assessment as required by facility policy. In addition, during an observed neurogenic bowel treatment and dressing change to a gluteal wound, two RNs repeatedly changed gloves without performing hand hygiene between glove changes, despite contact with stool and the wound area, contrary to the facility’s hand hygiene policy and the DON’s expectations for hand hygiene during wound care.
The deficiency involves multiple failures in pressure ulcer prevention, assessment, and treatment for several residents. A resident admitted without ulcers developed an in-house Stage 2 sacral pressure injury that was not consistently measured or fully assessed for several weeks, despite documented infection and worsening appearance. Staff did not reliably notify the NP or MD of deterioration, did not change treatment orders in a timely manner, and did not update the care plan with new interventions, while the resident reported not being repositioned every 2 hours and sometimes remaining in a saturated brief overnight. Another resident with incontinence-associated dermatitis and documented skin risk had wound assessments with missing or inconsistent measurements, photos showing apparent Stage 2 sacral/coccygeal ulcers that were not documented as such, and a care plan that did not reflect the specific skin issues or interventions identified on the MDS. Staff interviews and the DON’s statements confirmed gaps in CNA reporting, nurse assessment, physician notification, and overall wound care practices.
A resident with paraplegia and a stage 4 sacral pressure ulcer had specific wound clinic orders for acetic acid application, Calmoseptine to the buttock wound, Melgisorb Ag to the wound base, air time, and then ABD dressing with tape. An RN did not leave the acetic acid–soaked gauze in place for the ordered duration, did not provide ordered air time, placed the resident on the bed without a barrier and with the wound uncovered, and repeatedly touched the computer and wound care supplies without performing hand hygiene. The RN also used the same gloved hand to apply Calmoseptine to multiple wounds and then handle and cut Melgisorb Ag before dressing the wound and documenting the treatment as completed per orders.
Failure to provide and document ordered wound care for two residents with complex pressure ulcers and other wounds. One resident had severe skin breakdown, was totally dependent, and had a sacral wound that progressed to Stage IV while multiple treatments were missed and refusals were not fully documented or reported to the MD. Another resident, also totally dependent with multiple diagnoses and devices, had missed wound treatments for the scrotum, groin, foot, ankle, and heel, with no charted reason for refusals or evidence the MD was notified.
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