The wound began as minor skin irritation but opened into an unstageable pressure injury measuring 6 centimeters long and 4 centimeters wide by September 29, according to federal inspection records from Desert Canyon Post Acute.
Treatment Nurse 1 discovered the dramatic change during a wound assessment but never created the required change of condition report or contacted the resident's physician. The nurse told inspectors he notified an RN supervisor but couldn't remember who.
"There is no way to determine if the RP and or MD was notified of Resident 3's COC," the treatment nurse admitted during questioning on December 1.
The resident's treatment records show a complete gap in wound care from September 24 through September 28. The nurse acknowledged that without documentation, "we cannot say the wound care was done."
When the treatment nurse returned on September 29, he ordered medical-grade honey dressing for the now-serious injury. The facility's Director of Nursing confirmed the wound change should have triggered an immediate change of condition report.
"Not having a COC for the increase in the wound size means not be able to monitor, potentially not be able to treat the wound," the nursing director told inspectors. She added that failing to notify the physician "can also affect the treatment plan and delay the care."
The resident's wound monitoring records reveal another breakdown in care. No weekly assessment was completed for September 23, creating what the treatment nurse called "a potential for a delay in care."
Federal inspectors found that Treatment Nurse 1 was responsible for both assessing wounds and providing treatment. When asked about the five-day treatment gap, he stated there was "a potential for the wound to increase in size and worsen" without proper care.
The facility's own policies require staff to notify physicians about significant changes in residents' physical conditions. The policy also mandates weekly skin evaluations, especially when conditions change.
By the time proper treatment resumed, the minor skin irritation had progressed to require specialized medical honey applications and foam dressings on every shift. The treatment plan called for 14 days of intensive wound care.
The nursing director acknowledged during her interview that the wound increase "would require its own COC" under facility protocols. She confirmed that change of condition reports are created whenever wounds develop, increase in size, or require different staging.
Treatment Nurse 1 initially told inspectors that a change of condition report existed for September 29 but later admitted it covered a different issue entirely. No documentation exists showing that medical staff were alerted to the resident's deteriorating wound.
The inspection revealed systematic failures in wound monitoring at the facility. Weekly assessments were missed, required notifications were skipped, and treatment gaps lasted nearly a week while a resident's condition worsened.
Federal regulations require nursing homes to ensure residents receive proper wound care and that physicians are promptly notified of significant changes. The facility's policies mirror these requirements but weren't followed in this case.
The treatment nurse's acknowledgment that undocumented care "cannot say the wound care was done" highlights the documentation failures that left the resident without proper monitoring during a critical period.
When Treatment Nurse 1 finally returned to assess the wound on September 29, the transformation from minor irritation to serious injury was complete. The resident now faced weeks of intensive treatment with medical honey and daily dressing changes.
The nursing director's admission that physician notification failures "can affect the treatment plan and delay care" underscores the potential consequences of the communication breakdown.
Five days without wound care. No physician notification of a doubling wound size. Missing weekly assessments during a critical period. The resident's deteriorating condition went unmonitored while treatment protocols collapsed around basic care responsibilities.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Desert Canyon Post Acute, LLC from 2025-12-01 including all violations, facility responses, and corrective action plans.
Additional Resources
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