The nurse documented the 7-centimeter wound as a deep tissue injury instead of an unstageable pressure ulcer, a critical distinction that determines treatment protocols. Federal inspectors found the misdiagnosis placed the resident at risk for wound deterioration.
Resident 3 developed the large wound on their sacral coccyx area near the tailbone. By September 17, the pressure ulcer measured 7.2 centimeters in length and 6.2 centimeters in width. Sixty percent showed granulation tissue, indicating healing, while 40 percent contained slough — dead, yellowish tissue that prevents proper healing.
The wound care specialist who examined the resident on September 17 immediately identified it as an unstageable pressure ulcer. The specialist performed sharp excisional debridement, cutting away necrotic subcutaneous tissue that had turned black, brown, and yellow from lack of blood flow.
But for weeks before that intervention, LVN 1 had been assessing and documenting the wound incorrectly.
During interviews with federal inspectors on October 31, LVN 1 admitted the error. He stated that based on the wound's appearance and characteristics, including the presence of exudate, the resident's wound should have been identified as an unstageable pressure ulcer rather than a deep tissue injury.
"LVN 1 stated that he was unable to assess Resident 3's wound accurately," inspectors wrote.
The misdiagnosis had immediate consequences for the resident's care. LVN 1 told inspectors that appropriate interventions for an unstageable pressure ulcer were not implemented. Instead, the resident received interventions designed for a deep tissue injury — a fundamentally different type of wound requiring different treatment.
LVN 1 acknowledged multiple failures in his assessment and care of the resident. He told inspectors he should have assessed the resident for pain, developed an appropriate care plan, and provided proper wound care management and treatment for the unstageable pressure ulcer.
The distinction between wound types is critical in nursing home care. Deep tissue injuries typically appear as purple or maroon localized areas of discolored intact skin, while unstageable pressure ulcers involve full-thickness tissue loss where the base is covered by slough or eschar that obscures the true depth.
Treatment protocols differ significantly between the two conditions. Unstageable pressure ulcers require aggressive wound care management, including debridement of dead tissue, moisture management, and specific dressing protocols. The resident missed weeks of appropriate treatment due to the misdiagnosis.
LVN 1 completed skin and wound evaluation forms on September 6, September 15, and September 22. On September 15, he performed and documented his findings on the facility's evaluation form, but inspectors found his assessment inaccurate throughout this period.
The Director of Nursing confirmed the severity of the error during a November 4 interview. She stated that LVN 1 should have accurately identified and assessed the resident's wound from the beginning.
"The DON stated that as a result of the inaccurate assessment, Resident 3 did not receive appropriate interventions, management and care for an unstageable pressure ulcer, placing Resident 3 at risk for pressure ulcer deterioration," inspectors documented.
The facility's own policies emphasize the importance of accurate wound assessment. Their pressure sore staging policy, last reviewed on October 20, states it is the facility's policy to provide appropriate staging of pressure sores.
Their pressure sore management policy goes further, indicating that "all available measures shall be taken to reduce skin breakdown and pressure sores" and that "individual care plans for management of skin condition will be developed as indicated."
Yet the resident's care plan remained inadequate for weeks because of the fundamental misdiagnosis of their wound type.
The case illustrates how assessment errors can cascade through a resident's care. When LVN 1 incorrectly documented the wound as a deep tissue injury, it triggered the wrong treatment protocols, prevented appropriate interventions, and delayed the aggressive wound care the resident needed.
By the time the wound care specialist correctly identified the pressure ulcer on September 17, significant debridement was necessary to remove dead tissue that had accumulated. The specialist had to cut away necrotic subcutaneous tissue that appears when wounds lack proper blood flow or suffer severe injury.
The resident's wound showed signs of both healing and deterioration when inspectors observed it. While 60 percent displayed healthy granulation tissue with its characteristic red, bumpy appearance, 40 percent remained covered in slough — the soft, stringy, creamy-textured dead tissue that prevents wounds from healing properly.
Light serous exudate was also present, indicating ongoing wound drainage that required specific management protocols.
Federal inspectors classified the violation as causing minimal harm or potential for actual harm, affecting few residents. But for Resident 3, the weeks of inappropriate treatment represented a significant failure in basic wound care management.
The case occurred during a complaint investigation at the 120-bed facility in Van Nuys. California Healthcare and Rehabilitation Center has faced previous federal scrutiny, though this inspection focused specifically on wound care assessment and management failures.
LVN 1's admission that he "failed to recognize and document Resident 3's wound accurately" highlights the human cost of clinical errors in nursing home settings. What began as an assessment mistake evolved into weeks of inappropriate treatment for a resident with a serious, deteriorating wound condition.
The resident ultimately received proper care once the wound care specialist intervened, but only after enduring weeks of treatment designed for a different type of injury entirely.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for California Healthcare and Rehabilitation Center from 2025-11-18 including all violations, facility responses, and corrective action plans.
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