Incomplete wound tracking and missing pressure relief measures were identified for two residents with pressure ulcers or high pressure ulcer risk. One resident with a coccyx pressure injury had a missing week of comprehensive wound measurements, while another resident with diabetes, dementia, and chronic foot wounds was observed with heels and feet resting on the mattress instead of being elevated, despite care plans calling for pressure reduction, turning/repositioning, and weekly skin checks.
Failure to complete ordered wound treatments was identified for a resident with a stage three pressure ulcer of the right ankle. The resident had diagnoses including brain cancer, cerebrovascular disease, and depression, and was at risk for skin breakdown. The TAR showed missed wound care on several occasions and false documentation that treatments were completed on other days. During observation, the dressing was dated several days earlier and no calcium alginate was in place under the dressing; the ADON and DON verified the wound care had not been completed per MD orders and that the updated wound treatment order had not been implemented.
Missed Ordered Wound Care for Stage IV Pressure Ulcer: A resident with a stage IV pressure ulcer and multiple serious diagnoses, including DM2 and respiratory failure, had an order for daily wound care to the sacrococcyx and bilateral buttocks. The TAR showed no documentation that the ordered treatment was provided on several days, and the DON confirmed there were no progress notes explaining why the wound care was not done. The facility policy required wound treatments to be provided per physician orders and documented on the TAR.
Failure to provide ordered pressure ulcer care led to a resident’s coccyx wound worsening from Stage II to Stage III and remaining inconsistently treated. The resident had multiple chronic conditions, required extensive ADL assistance, and had repeated gaps in wound assessments and TAR documentation. Staff also missed ordered treatments, used the wrong wound products, and an RN altered the wound order without consulting the physician or WCNP; during dressing care, the RN also broke sterile technique and directed an LPN to backdate a dressing.
Air Mattress Set Incorrectly for Resident at Risk for Skin Breakdown: A resident with ESRD, atrial fibrillation, decreased mobility, incontinence, edema, oxygen use, and a history of pressure ulcers had an order for the bed to be on level four every shift, but observations and staff interviews confirmed the alternating air mattress was set to level five instead.
A resident with severe cognitive impairment, diabetes, CKD, malnutrition, incontinence, and multiple pressure ulcers had an unstageable right knee wound with an order for daily calcium alginate with silver and foam dressing changes. The TAR showed missed treatments on four consecutive days, and the wound later increased in size; the wound nurse and regional nurse confirmed the missed documentation, and the wound NP acknowledged the gap in recorded wound care.
A resident with severe cognitive impairment, total ADL dependence, and bladder and bowel incontinence had a coccyx pressure injury that was not accurately identified on the admission skin assessment. The care plan was incomplete, wound tx was not ordered until several days after admission, and weekly skin observations were not completed timely and consistently. The wound note later documented a stage 2 pressure injury with drainage, and the MDS RN and Wound LPN/ADON confirmed the assessment and care plan deficiencies.
A resident who was dependent on staff for mobility and personal care, and who had multiple chronic conditions and documented pressure injury risk, developed an unstageable pressure injury to the buttock after the facility did not implement or document turning/repositioning, pressure relief devices, or other prevention measures. The record showed MASD on re-entry, no documented wound care or pressure relief interventions when the skin issue was first identified, no pressure-relieving device in the wheelchair, and delayed documentation of the wound before it was later staged as an unstageable injury and then a Stage III ulcer.
An LPN and RN provided wound care to a resident with multiple Stage II pressure ulcers and other open areas, but the LPN did not cleanse each wound before applying treatment and did not wash hands or change gloves between separate wound sites. The resident had wounds on the buttocks, sacrum, and posterior thigh, and the LPN stated she believed cleansing and glove changes were unnecessary because the orders did not specify cleansing. The wound care nurse/ADON stated wounds should always be cleansed before treatment and that staff should wash hands and change gloves between wounds.
Failure to assess and treat a pressure ulcer timely: A resident with dementia and multiple chronic conditions was assessed as at moderate risk for skin breakdown, yet a skilled nursing assessment documented intact skin and no wound care. The resident was later found by the NP to have a right ankle pressure ulcer, but the ordered dressing, ointment, and offloading boot were not entered into the computer, and the wound MD then documented a stage III pressure injury to the lateral ankle.
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