RN A admitted she couldn't complete wound care for Resident #1 on October 1 because she was too busy. She worked the day shift from 6 a.m. to 6 p.m. but never informed the night nurse that treatments were left undone.
"RN A stated she was expected to inform the DON and ADON of not completing the wound cares, but she did not because she forgot," inspectors wrote.
The pattern repeated four days later. RN B, responsible for the same resident's care on October 3, also skipped the scheduled wound treatments.
"RN B stated wound care for the resident was scheduled on 10/03/25 but she could not complete it because she was busy and forgot to report to the oncoming charge nurse," the inspection report stated.
Both nurses understood the consequences of their actions. RN A told investigators that wound care not completed "could cause infection and or the wound getting worse." RN B echoed this assessment, saying missed treatments "could lead to the wound getting infected or getting worse."
The Director of Nursing discovered the lapses only when federal inspectors arrived to investigate. She had received no reports from either nurse about the missed treatments.
"The DON revealed she was not aware, and the staff had not informed her of not completing Resident #1's wound care," inspectors found.
The facility's own policy, last revised in July 2015, requires that residents with pressure ulcers receive necessary treatment to promote healing and prevent infection. Once a wound is identified and assessed, nursing staff must administer treatment according to physician orders.
The DON told investigators she expected charge nurses to complete wound care as scheduled. If they couldn't finish treatments during their shift, they were supposed to inform the next nurse and report the issue to supervisors.
"The DON stated the ADON was responsible to follow up and make sure wound cares were completed, but during the investigation the ADON was not present," the report noted.
RN A had last completed wound care for the resident on September 30. She told inspectors the wounds showed no signs of infection and had not deteriorated at that time. RN B similarly reported no deterioration from her previous wound care sessions.
The DON said morning meetings and wound care reports had not indicated the resident's wounds were worsening. A wound care doctor assessed the wounds weekly, she added.
However, the facility's Assistant Director of Nursing, who was supposed to follow up on wound care completion, was not present during the investigation. This left a gap in the oversight system designed to catch exactly these types of missed treatments.
The DON acknowledged to inspectors that wound care not completed per physician orders "could lead to the wound not healing properly and could cause infection to the wound."
Federal inspectors cited the facility for failing to ensure residents with pressure ulcers received necessary treatment and services. The violation affected some residents and was classified as causing minimal harm or potential for actual harm.
The inspection revealed a breakdown in both care delivery and communication systems. Nurses admitted being too busy to complete required treatments, then compounded the problem by failing to inform colleagues or supervisors about the gaps in care.
RN A worked Wednesday and Sunday shifts but left wound care undone on Wednesday without telling the night nurse. RN B covered Thursday but also skipped the treatments without passing information to the next shift.
The facility's wound management policy specifically states that nursing should administer treatment to each affected area as per physician orders once a wound has been identified and documented. Both nurses violated this requirement while acknowledging they understood the medical risks.
The investigation occurred October 6, nearly a week after the first missed treatment. During that time, the resident went without scheduled wound care on at least two documented occasions, with supervisors unaware of the lapses until federal investigators arrived.
Neither the inspection report nor facility documentation indicated whether the resident's wounds had deteriorated during the period when treatments were skipped. The DON noted that weekly assessments by the wound care doctor had not flagged problems, but the missed treatments represented clear departures from the prescribed care plan.
The case illustrates how staffing pressures can lead to skipped medical treatments, and how communication failures can prevent facilities from identifying and correcting care gaps before they potentially harm residents.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Carrollton Health and Rehabilitation Center from 2025-12-01 including all violations, facility responses, and corrective action plans.
Additional Resources
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