The resident, identified only as Resident #23, was admitted for rehabilitation and management of chronic health conditions. By late July, weekly skin team notes documented five trauma injuries plus deep tissue injuries on both heels that required immediate attention.
The wound care physician, Staff #21, ordered specific treatments. For the right heel, betadine should be applied and left open to air. For the left heel, the same betadine treatment until August 22, when it should switch to calcium alginate dressing.
None of that happened.
Instead, nursing staff applied skin prep wipes to the right heel every day and evening shift from July 19 through September 5. The physician's prescribed betadine was never applied to the right heel at all.
The left heel received equally incorrect care. From August 14 through August 29, nurses applied Xeroform petrolatum dressing pads each morning, cleansing the wound with saline, patting it dry, and wrapping it with gauze and tape. This daily routine continued for two weeks despite the physician's order for betadine treatment left open to air.
When the treatment was supposed to change to calcium alginate on August 22, that didn't happen either. The calcium alginate wasn't started until August 29, a full week late.
The Director of Nursing discovered the pattern during the September 29 inspection. "There appeared to be a problem on that unit," he told investigators. "He can't believe the nurses are not following the wound care orders."
The wound care physician explained the medical reasoning behind his specific orders during a September 26 interview. Santyl dressing, which some staff had been applying three times daily to another resident, was only meant to be used once per day. "The intention was for once a day," Staff #21 said. "Doing it 3 times of day has no value and is overkill."
But the problems extended beyond frequency to fundamental misunderstanding of treatment protocols. The August 2025 Treatment Administration Record documented exactly what nurses were doing versus what they were supposed to do, creating a paper trail of systematic non-compliance.
Weekly skin team notes from August 15 and August 22 showed the facility's own wound care team documenting the correct treatments. The August 15 note specified "betadine LOTA (leave open to air)" for both heels. The August 22 note documented the treatment change for the left heel to "calcium alginate and wrap with Kerlix."
Yet the nursing staff continued their incorrect protocols. The Treatment Administration Record showed nurses applying completely different materials and following procedures that contradicted both the physician's orders and their own facility's wound care team recommendations.
The inspection revealed a disconnect between medical orders, facility documentation, and actual nursing practice. While the wound care physician provided clear, medically appropriate instructions and the facility's skin team documented the correct treatments in their weekly notes, the bedside nurses followed their own protocols.
Staff #21 emphasized that his orders were straightforward. For wounds requiring Santyl dressing, the order "was for once a day and prn (when necessary) if the dressing comes off. Just once a day." He explained that excessive application "doesn't change the outcome of the wound" and described the three-times-daily routine some nurses were following as having "no value."
The Director of Nursing's September 22 acknowledgment that orders "should have been for every day, not every shift" suggested ongoing confusion about basic treatment frequencies across multiple residents.
The facility's own records documented the scope of the problem. Resident #23's case represented systematic failure to implement physician orders for wound care, with nursing staff applying incorrect treatments for weeks while the resident's deep tissue injuries required specialized medical attention.
The inspection found that some residents were affected by these wound care compliance failures, though the level of harm was classified as minimal or potential for actual harm. The gap between physician orders and nursing implementation continued until investigators discovered the discrepancies during their September review.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Lorien Health Systems - Columbia from 2025-09-29 including all violations, facility responses, and corrective action plans.
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