A resident admitted with sepsis, peripheral vascular disease, a surgically debrided pressure-related hip wound, and additional wounds to the sacrum and great toe had physician orders for a wound vac to the right hip, daily wound care to the toe and sacrum, and heel protection. Although the wound vac and supplies were already in the facility and staff nurses were reported by the DON to be knowledgeable in wound vac application, the wound care nurse did not work weekends and the wound vac was not applied on admission, but instead was initiated several days later when she returned. The wound care nurse also reported she was unaware that the hip wound was a pressure area surgically debrided in the hospital, contributing to the delay in implementing the ordered pressure ulcer treatment.
Pressure ulcer care, wound treatment, and care plan failures: Two residents had deficiencies involving pressure injury management. One resident with severe cognitive impairment, total ADL dependence, diabetes, and a PEG tube developed facility-acquired pressure ulcers while turning/repositioning and skin checks were frequently undocumented, the care plan was not revised after wound changes, and ordered sacral treatment was not documented as performed. Another resident admitted with sepsis, necrotizing fasciitis, paraplegia, and stage 4 pressure injuries had delayed wound vac changes, inconsistent skin assessments, and missing documentation for ordered wound treatments.
Two residents with pressure ulcers received wound care that was not performed in a sanitary manner. For a resident with a sacral pressure ulcer and multiple comorbidities, an LPN, assisted by a CNA, conducted a dressing change without placing a clean barrier between the open sacral wound and a contaminated diaper and Hoyer lift net padding, allowing the uncovered wound to rest on and repeatedly contact these contaminated surfaces during the procedure. For another resident with a mid-upper back pressure ulcer and chronic conditions including COPD, hypertension, GERD, and epilepsy, the same LPN and CNA performed a dressing change without a clean barrier between the uncovered back wound and contaminated bedding, allowing the wound area to contact the bedding throughout the treatment. The LPN later acknowledged not using a clean barrier, and leadership confirmed that the dressing changes should have been done in a safe and sanitary manner.
A resident admitted from the hospital with multiple documented pressure injuries to the sacrum, buttocks, and gluteal folds did not receive timely and appropriate wound treatment. Admission records and physician orders required daily monitoring and every-shift skin observations but contained no specific wound care treatment orders, and nursing staff did not obtain such orders. During a skin assessment, the DON and an RN found a large open area with a dark center on the lower back and additional open areas on the lower buttocks/upper thighs, with drainage noted on the incontinence brief and no dressings in place despite the resident having arrived with dressings. The RN could not explain the absence of dressings, and the wound NP reported she had not been contacted to see the new admit sooner or to provide interim treatment guidance, contrary to the facility’s wound management policy requiring evidence-based treatments and physician-directed wound care.
A resident with dementia, severe cognitive impairment, incontinence, weight loss, and existing stage 3 pressure ulcers to the left buttock and sacrum was care planned for skin integrity and ordered daily, then twice-daily, wound care with as-needed dressing changes. Documentation showed that ordered wound care was missed on at least two occasions without explanation, while the left buttock wound resolved but the sacral wound deteriorated from stage 3 to stage 4. Subsequent testing showed the sacral wound was infected with multiple bacteria and associated with osteomyelitis.
A resident was admitted with an old, non-open sacral area and extensive bruising to the abdomen, back, and thigh, but subsequent nursing notes and a weekly skin assessment documented the skin as intact with no wounds. Later, a physician identified unstageable DTI wounds to the right heel and sacrum and ordered daily skin prep and hydrocolloid dressings, and the care plan was revised for skin breakdown risk. The resident was hospitalized for abdominal pain and a psoas hematoma while on anticoagulant therapy, then readmitted with ongoing bruising, an open sacral area, and a DTI to the right heel, again requiring wound care orders and care plan revision. These events show that staff failed to consistently recognize, document, and monitor the resident’s bruising and pressure-related wounds in accordance with the facility’s wound management policy.
Improper wound care technique during pressure ulcer treatment: A resident with quadriplegia, chronic osteomyelitis, severe malnutrition, and multiple pressure ulcers received wound care that did not follow the ordered treatment. The wound care RN cleansed the wound beds and surrounding skin with Dakin’s solution, reused the same tongue depressor across all 3 wounds to apply silver gel, applied gel to peri-wound skin, and placed one long Dakin’s-soaked gauze strip across healthy skin between the wounds. The wound care NP stated the peri-wound should not have been cleansed with Dakin’s, the silver gel should not have been applied to peri-wound skin, and the gauze should have been limited to each wound bed.
A resident with dementia, muscle weakness, a hip fracture, and an existing stage 2 pressure ulcer developed a deteriorating pressure injury that progressed from stage 3 to stage 4 with exposed bone after the facility failed to implement revised wound specialist orders. The Wound Care PA ordered changes from collagen and honey gel to Santyl with calcium alginate and later added Xeroform and recommended imaging for suspected osteomyelitis, but the LPN responsible for wound care did not enter or implement these revised orders, and the TARs continued to show the original treatment. The LPN later claimed the PCP verbally overrode the PA’s orders, yet there was no documentation of such orders, no notification to the PA, and no care plan update for the pressure wound. The DON confirmed that the revised orders and imaging were never entered, while the Medical Director stated he relied on the wound specialist and did not order an X-ray, deferring to an orthopedic visit that did not address the wound. Facility policies requiring adherence to physician orders, documentation when orders are not followed, and revision of the care plan based on the resident’s condition were not followed, and the resident was ultimately hospitalized with an infected mid-back pressure wound and MRSA bacteremia.
A resident who was dependent on staff for toileting and bed mobility developed Stage 3 and Stage 4 pressure ulcers after no preventive interventions or physician orders were in place prior to the onset of skin breakdown. Staff confirmed that the care plan did not address pressure ulcer risk until after wounds developed.
A resident with severe frailty, contractures, and multiple comorbidities was admitted for respite care and assessed as high risk for pressure wounds. Despite physician recommendations for frequent repositioning, use of positioning supports, and pressure-relieving devices, these interventions were not included in the care plan or consistently provided. The resident developed multiple new pressure wounds, leading to severe infection and subsequent amputation, with staff confirming that key preventive measures were not implemented.
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