Meridian Meadows: Wrong Wound Care Orders - ID

Federal inspectors observed RN #1 performing wound care on Resident #5 on April 3. The nurse removed the soiled dressing, cleansed the wound with wound cleanser and gauze, patted it dry, applied skin prep, and covered it with a clean dry dressing.

The treatment was wrong. The physician had ordered staff to apply normal saline-moistened gauze before the dry dressing.

Fifteen minutes later, RN #1 admitted she had performed the incorrect treatment. The assistant director of nursing confirmed the wound care was not consistent with the physician's order.

Resident #5 had been admitted with multiple diagnoses including palliative care encounter, congestive heart failure, and acute kidney disease. Her care plan documented she was at risk for skin impairment and pressure ulcers.

The wound care failures stretched back days. On March 27, a physician ordered staff to discontinue the wound vacuum device on Resident #5's left heel and apply wet-to-dry dressing until further orders were received.

The facility stopped using the wound vacuum. But they failed to start any new treatment.

For four days, Resident #5 received no wound care on her left heel. The new physician order for cleansing with wound cleanser, applying normal saline-moistened gauze, and covering with dry dressing every shift was not implemented until March 31.

The assistant director of nursing blamed communication problems with the hospice agency. He said the facility had difficulty clarifying the wound care order and acknowledged he did not think to obtain a temporary order from the facility's medical director.

Before the wound vacuum was discontinued, Resident #5's treatment had been complex. Staff were ordered to cleanse the wound, apply skin prep, place black foam, cover with transparent dressing, and maintain negative pressure at -125 mmHg continuously. The device was changed twice weekly.

The facility also had standing orders to remove the wound vacuum and apply wet-to-dry dressing if the device was nonfunctional for more than two hours and notify the provider.

But when the physician ordered the wound vacuum discontinued on March 27, no immediate replacement treatment was documented in the nursing progress notes. The gap lasted until March 31.

Other wounds on Resident #5 had clearer orders. Her right lateral foot and left medial foot were to be cleansed with wound cleanser and covered with Mepilex border or similar bandage once daily every Monday and Thursday. Those treatments appeared to continue without interruption.

The left heel wound was different. It had required the more intensive wound vacuum therapy, suggesting more serious tissue damage or slower healing. When that therapy was discontinued, the wound needed consistent daily care with saline-moistened gauze to maintain proper moisture balance and promote healing.

Instead, Resident #5 went four days with no documented wound care, then received incorrect treatment when care resumed.

Federal inspectors classified the violation as creating potential for delayed healing and wound deterioration. The finding affected one resident but highlighted broader communication and care coordination problems.

The facility's treatment administration records showed the gap between discontinuing one therapy and implementing another. The nursing progress notes failed to document what replacement treatment would be provided when the wound vacuum was stopped.

For a patient receiving palliative care, proper wound management affects comfort and quality of life. Untreated or improperly treated wounds can cause pain, infection, and further tissue breakdown.

The assistant director of nursing's admission that he did not think to obtain temporary orders from the facility's medical director revealed a gap in clinical decision-making when communication with outside providers broke down.

Resident #5 remained at the facility during the inspection, still requiring daily wound care for her heel according to the physician's orders that staff had been failing to follow correctly.

Full Inspection Report

The details above represent a summary of key findings. View the complete inspection report for Meridian Meadows Transitional Care from 2026-04-03 including all violations, facility responses, and corrective action plans.

Additional Resources

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