Failure to provide ordered wound care for three residents with wounds and pressure ulcers. One resident with a stage 3 ulcer and skin breakdown, one resident with a stage 2 pressure ulcer, and one resident with a skin tear abrasion all had MAR blanks showing missed treatments. LPNs confirmed the care was not completed, citing lack of wound care education, discomfort performing the treatments, uncertainty about responsibility, and high acuity on the hall. DONs confirmed that blank MAR entries meant the care was not done.
Failure to provide appropriate pressure ulcer care occurred when a resident with Parkinson's disease and a Stage IV sacral PU was not repositioned every 2 hours as ordered. The resident's care plan and physician orders required q2h turning/repositioning, but staff observed the resident remained on the same side for hours after wound care. An RN confirmed the resident was high risk for skin impairment, and an AB stated she only repositioned the resident about every 3 hours due to other duties.
A resident with a Stage 4 sacral pressure ulcer and moderate cognitive impairment was observed multiple times lying on a deflated air mattress with the pump off and unplugged. The resident stated she was uncomfortable and felt like she was lying on the bedframe. Staff confirmed the air mattress should have been on and functioning properly at all times and checked during rounds.
A resident admitted without pressure ulcers, with Alzheimer’s disease, dementia, malnutrition, and anorexia, was assessed as at moderate risk for pressure injury and required significant assistance with mobility. A skin check documented no heel issues, but the next day a DTI was found on the right heel during am care. The DON stated the heels were not assessed during the skin evaluation and could not provide documentation that heel floating or heel boots were in use before the injury was identified.
Failure to assess skin during and after moist heat therapy led to a burn injury for a resident with DM, PVD, venous insufficiency, malnutrition, and lymphedema. The resident reported a heating pad applied for muscle tightness burned the right lower leg, and later a fluid-filled blister was noted. The PT acknowledged the resident’s skin was not assessed or documented during and after the procedure.
A facility failed to protect two residents with wounds by not maintaining EBP signage and by allowing a resident with a stage 3 ankle pressure injury to be showered with open wounds. The wound care nurse later noted the ankle wound had deteriorated and appeared frail and mushy, and a RN said the resident’s wounds were not dressed, only covered with a plastic bag that collected water. Staff also confirmed that EBP signage was missing from both residents’ rooms.
Failure to provide pressure ulcer care occurred when a resident with CVA and mild-protein calorie malnutrition, and a Braden score indicating high risk for skin breakdown, was ordered bilateral heel protectors at all times but was repeatedly observed without them while in a geri-chair and in bed. CNAs confirmed the resident did not have heel protectors as a pressure ulcer intervention, and the DON stated ordered heel protectors should have been placed on the resident.
Failure to provide timely pressure ulcer care and turning documentation. A resident with dementia and other medical conditions developed a new sacral PU that was identified by hospice, with orders for Dakin's gauze and later for side-to-side repositioning every 2 hours. The wound care was not documented until several days later, and the MAR/TAR did not reflect the turning order; hospice also found the resident lying on her back despite the order.
Staff failed to follow a resident’s physician orders and care plan requiring heel boots on both feet at all times while in bed. The resident had a stage 4 sacral PU and limited bed mobility, but observations repeatedly found only the left heel boot in place while the right boot was missing. Nursing staff noted redness on the right heel, and an LPN confirmed the ordered bilateral heel protection was not being maintained.
The facility failed to provide physician-ordered daily wound care for three residents with Stage II–IV pressure ulcers to the sacrum and heel. Each resident had specific orders for daily cleansing, application of Santyl and/or Collagenase, use of calcium alginate, and coverage with silicone foam border dressings, with changes every day and as needed. Treatment records showed that ordered wound care was not completed on multiple consecutive days, and dressings observed in place were dated several days earlier. The treatment nurse, LPNs assigned on those days, the DON, and a contracted wound care NP all acknowledged that the daily pressure ulcer treatments were not performed as ordered.
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