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.
A resident with severe cognitive impairment, CHF, type 2 DM with circulatory complications, morbid obesity, impaired mobility, and wheelchair use had physician orders and a care plan intervention for a pressure-reducing seat cushion every shift due to high risk for pressure ulcers. On the survey day, the resident was observed twice seated in a wheelchair without the ordered cushion. A CNA and an LPN both stated the resident required two-person assistance, was at risk for pressure ulcers, and had an order for a pressure-reducing cushion, yet confirmed no cushion was present in the wheelchair or the room. The DON verified that the cushion should have been in use whenever the resident was out of bed in the wheelchair.
Missed Skin Assessments and Wound Rounds for a Resident With a Heel Pressure Ulcer: A resident with spina bifida, DM2, and paraplegia had a right heel stage 2 pressure ulcer with wound care orders, but weekly skin audits did not identify the ulcer and wound rounds were not completed/documented for the wound. The LPN stated she did not identify or record the ulcer on the skin assessments and had not conducted wound rounds for the heel until the interview, and the DON confirmed the ulcer should have been included.
Two residents with existing pressure ulcers and high risk for skin breakdown did not receive ordered pressure-relief interventions and scheduled repositioning. One resident with multiple comorbidities and a Stage 2 heel ulcer had a care plan and posted signage requiring heel protectors, yet surveyors repeatedly observed the resident in bed or in a specialized wheelchair with heels on the mattress and the heel protectors stored on top of a closet; a family member reported never seeing them applied, and nursing staff acknowledged they should have been in use. Another resident with paraplegia, bilateral above-knee amputations, and Stage 4 buttock ulcers was care planned for a q2h turn schedule with wedges, but was repeatedly observed lying on his back with no supportive equipment while the wedges remained unused in a box; the resident stated staff did not turn or offer to turn him, and the assigned CNA and DON later acknowledged that q2h turning should have been provided but was not.
A resident with severe cognitive impairment, multiple sclerosis, hemiplegia, and a Stage 4 sacral pressure ulcer had physician orders and a care plan for sacral wound care three times weekly and as needed when soiled. During an observed treatment, a treatment nurse removed a saturated sacral dressing and completed the ordered wound care while leaving a soiled brief in place, then secured the same soiled brief on the resident afterward and replaced the bed linens. The nurse acknowledged the brief was soiled during treatment, and the DON stated the brief should have been changed before and not left on after the wound care, contrary to the facility’s pressure injury prevention policy requiring residents to be kept clean and dry.
Failure to maintain dressing on a stage 4 sacrococcyx pressure ulcer. A resident with severe malnutrition, vascular dementia, and C. diff had orders and WOC NP recommendations for daily wound cleansing and Urgoclean Ag with a dry dressing, changed as needed if soiled or dislodged. The RP reported the wound was worsening and staff were not changing the dressing when it was soiled with feces. On observation, the ulcer was uncovered, and the WOC LPN confirmed it should have been covered and that staff had not notified the nurse when the dressing became soiled or dislodged.
Failure to perform hand hygiene during pressure ulcer care. A resident with a sacral pressure ulcer and vascular dementia had wound care ordered for daily cleansing, skin prep, calcium alginate, and a dry dressing. During observed wound care, an RN cleaned the wound, reached over a clean field with soiled gloves, and repeatedly continued care without removing gloves or sanitizing hands; the RN confirmed this during interview.
Pressure ulcer care was not administered as ordered for a resident with a stage 3 PU. Records showed two separate wounds, one on the sacrum and one on the buttocks, but documentation and treatment records reflected care only for the sacral wound. A wound care NP later confirmed separate orders for both wounds, while an LPN/Treatment Nurse stated she did not recognize the resident as having two separate PUs and did not follow the updated wound care orders.
A resident with severe cognitive impairment, incontinence, a feeding tube, and existing pressure injuries had an inaccurate pressure ulcer assessment, no documented weekly body audits, and missing TAR documentation for multiple ordered wound treatments. The WCN, ADON, and DON confirmed the missing documentation and that weekly body audits should have been completed and recorded.
Nursing staff failed to document the date and their initials on wound dressings after treatments for two residents with pressure ulcers, and did not use dressings large enough to fully cover and protect a wound for one resident. Observations and staff interviews confirmed that dressings were missing required documentation and, in one case, did not fully cover the wound, leaving it exposed.
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