The incident occurred on November 5, 2025, at Advanced Health & Rehab Center of Garland, where Resident #1 had been receiving hospice care for approximately seven to eight months.
A hospice aide discovered the wound without its protective bandage during morning care around 9:00 AM. She had been specifically instructed never to remove the patient's wound care bandage herself.
"She stated there was not a bandage at the time she provided care," according to the inspection report. The aide looked for both the wound care nurse and the patient's assigned nurse to report the missing bandage but could not locate either of them.
The wound remained exposed until at least noon, when inspectors observed the condition during their facility visit.
Nobody had checked on the patient's wound status during those three hours.
The facility's administrator acknowledged the severity of the breakdown during interviews with inspectors on November 7. She stated it was her expectation for residents' wounds to be covered and dressed at all times to promote healing and prevent infection.
"Additionally, she stated it was not acceptable for Resident #1's sacral wound to be uncovered for any extended period of time," inspectors wrote.
The administrator said she expected both the hospice aide and the certified nursing assistant assigned to the patient to have checked his sacral area between 9:00 AM and noon, and to report any care needs to the nurse immediately.
She called the incident "a failure" that was not completed and said she would work with the facility's director of nursing to address the break in the system.
The exposed wound violated multiple facility policies designed to prevent infection and promote healing. The facility's pressure injury prevention and management policy, revised in April 2023, commits to providing evidence-based treatments to heal pressure injuries and prevent infection.
Hand hygiene protocols were also compromised. The administrator emphasized that staff must perform proper hand hygiene before and after resident care, particularly when moving from dirty to clean areas during incontinent care. This was described as crucial for preventing infection.
The facility's hand hygiene policy, dating to November 2017, requires staff in direct resident contact to wash hands after removing gloves, between resident contacts, after handling contaminated objects, and before and after removing personal protective equipment.
These protocols become especially critical for hospice patients like Resident #1, whose extended stay and medical condition make proper wound care essential for comfort and infection prevention.
The inspection revealed systemic communication failures between nursing staff and support personnel. The hospice aide's inability to locate appropriate nurses for three hours suggests either inadequate staffing coverage or poor communication systems for urgent care needs.
Wound care for hospice patients requires continuous attention since these residents often have compromised immune systems and healing capacity. Leaving wounds exposed increases infection risk and can cause additional pain for patients already dealing with end-of-life medical conditions.
The facility's own policies acknowledge this reality, stating commitment to preventing avoidable pressure injuries and providing treatment to heal existing wounds while preventing additional injury development.
The administrator's admission that the incident represented a system failure indicates awareness of the problem's scope beyond individual staff actions. Her promise to work with nursing leadership suggests recognition that procedural changes may be necessary to prevent similar incidents.
Federal regulations require nursing homes to provide necessary care and services to maintain each resident's highest level of well-being. For hospice patients, this includes consistent wound management protocols that ensure continuous coverage and immediate reporting of care disruptions.
The November inspection found the facility failed to meet these standards when multiple staff members could not locate appropriate nurses for three hours while a vulnerable patient's wound remained exposed and unprotected.
Resident #1 continued receiving hospice care at the facility, but the inspection documented how communication breakdowns can compromise even basic wound protection for the facility's most vulnerable patients.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Advanced Health & Rehab Center of Garland from 2025-11-26 including all violations, facility responses, and corrective action plans.
Additional Resources
- View all inspection reports for Advanced Health & Rehab Center of Garland
- Browse all TX nursing home inspections