Federal inspectors found the resident at Methodist Specialty Care Center on October 30 with no dressings on either foot, despite physician orders requiring specialized wound care coverings. The woman had a silver dollar-sized ruptured blister on her left heel with an open area measuring approximately one-eighth inch by one-quarter inch.
The resident was supposed to have calcium alginate dressing on her left foot to create a moist healing environment with antimicrobial agents. Her right foot required dry dressing to prevent skin injury. Neither was in place when inspectors arrived at 3:00 PM.
Registered Nurse #2, one of two contracted wound care specialists who work Monday through Friday, told inspectors she had applied fresh dressings to both of the resident's feet the previous day. The nurse said she expected to find dressings with her initials dated October 29 on both feet and "could not explain why there were not any in place."
The next scheduled dressing changes weren't due until October 31.
Nobody knew when the dressings disappeared or why no one reported they were missing. RN #3, the day shift supervisor, told inspectors "she did not know why Resident #1's dressings were not in place or why no one reported that the dressings needed to be changed or reapplied."
She also said she didn't know when the dressings were removed or why.
The facility's own policies required certified nursing assistants to immediately notify the resident's assigned nurse about any problems with existing dressings, including soilage or displacement. CNA #2 confirmed she had checked on the resident twice between 7:00 AM and 10:30 AM during her shift on the day inspectors arrived.
At 10:30 AM, staff reassigned the resident to CNA #3. Neither aide reported missing dressings to nursing staff.
The wound care orders specifically allowed any nurse on duty to change dressings as needed for soilage and displacement, even when the specialized wound care nurses weren't working. RN #2 confirmed that "any nurse on duty could change the dressings as needed" if they became soiled or displaced during off hours.
The missing dressings left the resident's wounds completely exposed. RN #2 explained that the calcium alginate dressing ordered for the left foot was crucial because it "promoted epithelial cell growth and wound closure with antimicrobial agents." The dry dressing for the right foot was designed "to prevent skin injury."
Without these protective coverings, the resident's healing process was compromised and her risk of infection increased.
The facility's Director of Nursing and Administrator both witnessed the resident's condition during the inspection. They confirmed the resident should have had dressings on both feet according to physician orders and acknowledged that "failure to ensure that Resident #1's dressings were clean, intact and applied correctly was not acceptable according to professional standards of practice."
The Administrator and Director of Nursing confirmed it was the responsibility of nurses to supervise resident care and the responsibility of nursing assistants to report any issues with wound dressings to nursing staff. Despite these clear protocols, the system failed completely.
The resident wore flex heel boots on both feet, but the protective footwear couldn't replace the specialized medical dressings her wounds required. The boots alone provided no antimicrobial protection or moisture control necessary for proper healing.
Federal inspectors found the facility failed to ensure residents received treatment and care in accordance with professional standards of practice. The violation affected few residents but created minimal harm or potential for actual harm.
The breakdown in wound care supervision occurred despite having dedicated wound care specialists on staff and clear policies for reporting dressing problems. Multiple staff members had opportunities to identify and address the missing dressings throughout the day, but none acted.
The resident's exposed wounds remained vulnerable to contamination and delayed healing while staff continued their shifts unaware that crucial medical treatment had been interrupted.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Methodist Specialty Care Center from 2025-10-30 including all violations, facility responses, and corrective action plans.
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