The resident, identified as R1 in state inspection records, required staff assistance for all activities of daily living and had intact cognition with a perfect score on mental status testing. The resident's treatment plan called for cleaning the wounds with wound cleanser, applying lidocaine ointment and betadine-packed gauze, then securing with ABD pads and tape every day shift.
But documentation showed no wound care occurred on September 6, September 7, September 20, and September 21.
The treatment nurse worked Monday through Friday from 8 a.m. to 4:30 p.m., leaving floor nurses responsible for treatments when she was absent. Weekend treatments fell to the RN supervisor.
The Director of Nursing confirmed the resident did not receive wound care on those four dates.
Stage 4 pressure ulcers represent the most severe category of bedsores, extending through skin and tissue down to muscle and bone. For a quadriplegic resident completely dependent on staff positioning and care, consistent wound treatment becomes critical to prevent infection and further tissue death.
The resident had been at Matthews Memorial Health Care Center since November 2021, with medical diagnoses including quadriplegia, pain, hypertension, urinary tract infections, and pressure ulcers to the right and left buttock as well as the sacral region. The care plan noted the resident's limited mobility related to quadriplegia made them dependent on staff for bed mobility, transfers, and toileting.
The September quarterly assessment revealed pressure-induced deep tissue damage to the right buttock in addition to the stage 4 ulcers.
Treatment records from September 1 through September 30 showed the gaps in documented care, raising questions about weekend supervision and treatment protocols when the regular treatment nurse was off duty.
A separate case mentioned in the inspection involved a resident with mouth pain from an abscess who needed antibiotics. The resident's physician said he would have called back if notified about the antibiotic need, and that nurses should have called back or contacted the facility's medical director about the resident's mouth pain.
The facility operates under a system where the treatment nurse handles wound care during weekdays, but responsibility shifts to floor nurses during her absence and to the RN supervisor on weekends. This handoff system appeared to break down during the four days when Resident R1's wound care was missed.
For a resident with quadriplegia, pressure ulcers develop from prolonged pressure on skin and tissue, typically over bony areas like the buttocks and sacrum. Without the ability to shift position independently, these residents rely entirely on staff for repositioning and wound prevention.
The inspection found the facility failed to ensure residents received necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being. The violation affected some residents and was classified as causing minimal harm or potential for actual harm.
Matthews Memorial's treatment protocols required daily wound care for stage 4 pressure ulcers, but the execution faltered when regular staff were absent. The gaps occurred across different days of the week, suggesting systemic issues rather than isolated oversights.
The resident's intact cognition meant they were fully aware of their condition and treatment schedule. Being dependent on staff for all care while mentally alert to missed treatments adds psychological distress to the physical consequences of inadequate wound management.
State inspectors documented the missed treatments through review of treatment administration records and interviews with nursing staff. The Director of Nursing's confirmation that care was missed on the four documented dates eliminated any ambiguity about whether treatments occurred but went undocumented.
The facility's weekend supervision structure placed responsibility for complex wound treatments on RN supervisors who may have had other competing priorities across the facility. This organizational gap left vulnerable residents like R1 without consistent daily care their conditions required.
Resident R1 remains at the facility with stage 4 pressure ulcers requiring ongoing daily treatment to prevent further deterioration and promote healing.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Matthews Memorial Health Care Center from 2025-09-29 including all violations, facility responses, and corrective action plans.
Additional Resources
- View all inspection reports for Matthews Memorial Health Care Center
- Browse all LA nursing home inspections