The facility failed to carry out ordered wound care and pressure-relief interventions for multiple residents. One resident’s ankle wound present on admission was not adequately assessed, monitored, or treated and later was documented as a Stage 4 pressure injury. Another resident’s Wound NP recommendations were not transcribed or implemented, and the resident’s air mattress was repeatedly found set far above the ordered weight-based setting. A third resident’s sacral wound care was not followed as ordered, the wound was not measured weekly, and the air mattress was also set too firm. A fourth resident’s heel wound dressing was not provided according to the physician’s order.
Failure to Implement Updated Wound Treatment Orders: A resident with multiple pressure ulcers, severe cognitive impairment, diabetes, and hemiplegia/hemiparesis did not receive the Wound MD’s updated sacral wound treatment recommendations. Nursing continued the prior Santyl-based order on the TAR even after the Wound MD directed calcium alginate and a superabsorbent dressing, and staff interviews confirmed the updated orders were expected to be entered promptly but were not in place.
A resident with diabetes, impaired mobility, pain, and high skin-breakdown risk did not receive consistent diabetic foot care, weekly skin checks, or timely response to a new red, non-blanchable heel area identified by therapy. Staff could not consistently visualize the foot because of an ace wrap that was not ordered, therapy reported the need for offloading and prevalon boots, and the heel later progressed to an unstageable pressure injury. After the wound was identified, the resident was still observed on a regular mattress despite an order for an air mattress, and staff gave inconsistent reports about whether it was being used.
Failure to float heels for a high-risk resident. A resident with DM, a right foot ulcer with muscle necrosis, and depression had an order to elevate legs and float heels while in bed. The resident was rated very high risk for pressure ulcers, but surveyors repeatedly observed both heels directly on the mattress, and the record did not show refusal of the ordered intervention. Staff interviews confirmed the order should have been followed and that the CNA did not recall seeing the heel-floating requirement.
Failure to elevate heels for a resident at risk for pressure ulcers. A resident with severe cognitive impairment, total ADL dependence, and a care plan/order for heel elevation was observed multiple times lying in bed with both heels directly on the mattress. Staff stated that CNAs and nurses were responsible for following the care plan and documenting any refusal or inability to tolerate the intervention.
Failure to Follow Pressure Ulcer Orders: A resident with dementia and a stage 3 unhealed heel pressure ulcer had orders to offload the wound every shift, float the heels in bed, and apply a specific daily dressing. Surveyors observed the resident's heels flat on the mattress in bed on multiple occasions and the feet resting on wheelchair supports, and during wound care an incorrect bordered gauze dressing was used instead of the ordered bordered foam dressing. The UM, Infection Prevention Nurse, and DON confirmed the ordered heel offloading and dressing were not followed.
Failure to implement wound treatment orders for a resident with a right heel DTI. A resident with severe cognitive impairment and neurocognitive disorder with Lewy bodies and Parkinson’s disease had a Wound MD order for Betadine plus ABD pad, gauze roll, and tape for an unstageable right medial heel DTI, but the MAR/TAR reflected skin prep and NS cleansing instead, with the Betadine order not entered until weeks later. Staff interviews showed the MD deferred to the Wound MD, the UM said wound recommendations were entered into the EHR, the Wound Nurse was unaware the Betadine treatment was not implemented, and the DON cited transcription issues.
Air Mattress Not Turned On for Resident at High Risk for Pressure Ulcers. A resident with a history of pressure ulcers and a high skin-breakdown risk was ordered to use an air mattress while in bed, but surveyors repeatedly observed the mattress turned off while the resident was sleeping and later while a CNA delivered lunch. The Unit Manager said the mattress was unplugged and then reconnected it, and the DON stated the mattress should always be plugged in and on while the resident was in bed for wound prevention.
A resident with a Stage 4 pressure ulcer on the left ischium/buttock did not receive the wound care ordered by the wound consultant. The consultant documented recurrent ulcer care with debridement and repeated orders for collagen dressing, alginate, and foam, then later changed the treatment to wound cleanser, Bactroban, alginate, and foam after odor and necrosis were noted. The record showed the facility instead used NS wash and alginate/foam or dry dressing, and the attending MD said she was not aware the consultant's recommendations were not being followed.
A facility failed to carry out ordered pressure injury prevention and treatment for three residents. One resident with frailty, severe cognitive impairment, and hospice involvement did not receive an ordered air mattress before developing a new Stage 2 pressure injury, and the wound initially lacked treatment orders and documented hospice/care plan follow-up. A second resident with a heel pressure ulcer was observed in bed without ordered Prevalon boots, and staff noted the boots should have been on. A third resident with a history of heel ulcers was repeatedly observed with the air mattress set incorrectly at the max setting and without ordered off-loading boots, despite staff confirming the resident did not refuse care.
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