CITYVIEW CARE CENTER – FORT WORTH, TX

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, interview, and record review, the facility failed to ensure residents were free from neglect for three (Residents #1, #2, and #3) of six residents reviewed for pressure ulcers.

The facility failed to prevent Resident #1 from developing Stage IV pressure ulcers on the inner aspect of each knee on 10/11/18 and surgically debrided (removing dead tissue resulting in a bleeding wound bed) the pressure ulcers without the consent of the resident’s family on 10/17/18. As a result, Resident #1’s pressure ulcers deteriorated until the resident’s passing at the facility on 10/22/18. The resident developed severe pain and was unable to tolerate wound care for the pressure ulcers starting on 10/20/18.

The facility failed to implement pressure ulcer prevention measures to prevent worsening of pressure ulcers on Resident #2. As a result, Resident #2 had pressure ulcers on both of her heels that worsened.

The facility failed to implement pressure ulcer prevention measures, outside of the use of an air loss mattress, to prevent worsening of pressure ulcers and development of new pressure ulcers for Resident #3. As a result, Resident #3 had pressure ulcers on her left foot and heel that worsened, and a new pressure ulcer that developed on her left foot.