LAREDO, TX – RETAMA MANOR/LAREDO SOUTH

Based on observation, interview, and record review the facility failed to ensure residents who entered the facility without pressure ulcers did not develop pressure ulcers and a resident having pressure ulcers received care and treatment consistent with professional standards of practice to promote healing and prevent further development of skin breakdown or pressure ulcers for seven (R #65, R #3, R #18, R #227, R #29, R #70, and R #79) of eight residents reviewed for pressure ulcers.

1.) Resident #65:

-The facility failed to assess and document a detailed description of R #65’s pressure ulcers upon admission.

-The facility’s documentation of R #65’s pressure ulcers was conflicting and inconsistent on separate forms making it difficult to track the progress and accurate staging of the pressure ulcers.

-The facility did not consistently identify all of R #65’s pressure ulcers in their Skin-Weekly Pressure Ulcer Record or the Skin Head to Toe Check.

-The facility did not reposition or attempt off-loading techniques of pressure points for R #65, whom was identified as at risk for pressure ulcer development, at least every two hours as determined by the facility.

-LVN [NAME] failed to perform hand hygiene practices as per the facility’s policy and procedure, prior to initiating and during R #65’s wound care on his pressure ulcers. R #65 had some infected ulcers [MEDICAL CONDITION].

-LVN [NAME] failed to consult with R #65’s physician when two new pressure ulcers were identified and before treating them.

-The facility failed to ensure the licensed staff providing wound care were knowledgeable and competent in the identification, assessment, documentation, and treatment of [REDACTED].

-Documentation of R #65’s Sacral ulcer revealed staff were inconsistent with staging and were back-staging, which was incorrect according to the facility’s policy and procedure and the National Pressure Ulcer Advisory Panel.

-The facility did not ensure or monitor R #65’s Low Air Loss Mattress was set at the appropriate setting for optimal therapy, as per the User-Guide.

-The facility did not ensure R #65 received necessary treatment and services thru proper use of low air loss mattresses, which was chosen as [MEDICATION NAME] to prevent the development of or worsening of pressure ulcers.

R #65’s Left Heel Pressure Ulcer was initially identified as a DTI however, deteriorated to an Unstageable Pressure Ulcer from admission to 03/07/18; Left Lateral Ankle and Left Lateral Leg Unstageable Pressure Ulcers slightly increased in size from admission to 03/07/18; Right Medial Heel Pressure Ulcer was initially identified as a Stage 2 however, deteriorated to an Unstageable Pressure Ulcer from admission to 03/07/18; Right Lateral Ankle Pressure Ulcer was initially identified as a Stage 2 however, deteriorated to an Unstageable pressure ulcer from admission to 03/07/18; Left Upper Back, Mid Upper Back, and Mid Lower Back Unstageable Pressure Ulcers developed depth to the ulcers that he did not have on admission; Sacral Pressure Ulcer deteriorated from a Stage 3 to a Stage 4 from admission to 03/07/18.

2) Resident #3:

-The facility did not reposition or attempt off-loading techniques of pressure points for R #3, whom was identified as at risk for pressure ulcer development, at least every two hours as determined by the facility.

-R #3’s Stage 3 pressure ulcer was left uncovered for an undetermined amount of time, despite R #3’s physician orders [REDACTED].

R #3 developed a facility acquired Stage 2 pressure ulcer to her sacrum which doubled in size and deteriorated to a Stage 3 pressure ulcer.

3) R #227:

-LVN S did not initiate documentation of R #227’s left upper posterior thigh medical device related pressure injury (MDRPI) that was discovered upon the surveyor’s inquiry.

-LVN S did not consult with R #227’s physician regarding the newly discovered MDRPI until a day later, upon the surveyor’s inquiry.

-The facility incorrectly identified R #227’s newly discovered wound to her left upper posterior thigh as a skin tear rather than a confirmed MDRPI.

R #227 developed a Stage 2 MDRPI in the facility five days after her admission to the facility.

4.) R #18:

-The facility’s incorrectly identified R #18’s right buttock pressure ulcer as a Stage 2, which did not meet the definition, according to the facility’s description of the wound.

-The facility’s documentation of R #18’s pressure ulcers was conflicting and inconsistent on separate forms making it difficult to track the progress and accurate staging of the pressure ulcers.

-The facility did not consistently identify all of R #18’s pressure ulcers in their Skin-Weekly Pressure Ulcer Record or the Skin Head to Toe Check. R #18 was admitted to the facility with a Right Buttock blister however two days later R #18’s blister deteriorated to a Stage 3 pressure ulcer and then to an Unstageable pressure ulcer.

5.) R #29 was not repositioned at least every two hours as determined by staff, on two separate occassions. R #29 was positioned on his left hip, which had a Stage 2 pressure ulcer, for over two hours. R #29 developed two Stage 2 pressure ulcers since admission to the facility.

6.) R #70:

-R #70 was admitted to the facility on [DATE] with no pressure ulcers. On 02/26/18 R #70 was identified to have a pressure ulcer to the Left Buttock Stage 2 and a pressure ulcer to the Right Buttock Stage 2 but the facilty failed to obtain a Physician order [REDACTED].>-R #70’s pressure ulcer was left uncovered for an undetermined amount of time, despite R #70’s physician orders [REDACTED].

-CNA X did not report to licensed staff that R #70’s pressure ulcer was uncovered. R #70 developed a Stage 2 pressure ulcer since admission to the facility.

7.) R #79:

-R #79 was admitted to the facility on [DATE] with three pressure ulcers, and the facility did not obtain physician orders [REDACTED]. The facility did not continue to monitor and document the status of all three pressure ulcers on an ongoing basis.

-LVN [NAME] incorrectly staged R #79’s left postereior thigh pressure ulcer as a Stage 2 despite it meeting the definition of a Stage 3.

-R #79’s Low Air Loss Mattress was set at the appropriate setting for optimal therapy, as per the User-Guide. R #79 was admitted to the facility with three Stage 2 pressure ulcers; R #79’s left posterior thigh pressure ulcer deteriorated to a Stage 3 pressure ulcer since admitted to the facility.

The above failures resulted in an IJ situation on 03/08/18. While the IJ was removed on 03/11/18, the facility remained out of compliance at actual harm with a scope identified as pattern. The facility was continuing to monitor to ensure continued implementation of their plan of removal.

These failures could place nine residents with pressure ulcers and 19 residents receiving preventive skin care at risk for developing new pressure ulcers or a deterioration in existing pressure ulcers.