LIBERTY NURSING CENTER OF COLERAIN – CINCINNATI, OH

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

Based on medical record review, hospital record review, observation, staff interviews, resident interview, review of the National Pressure Ulcer Advisory Panel (NPUAP) pressure ulcer staging guide, and review of facility policy, the facility failed to initiate and consistently follow physician ordered treatments to prevent the development of avoidable pressure ulcers and/or promote the healing of three (#42, #03, #60) of five residents reviewed for facility acquired pressure ulcers. This resulted in Immediate Jeopardy for two (#42 and #03) of five residents reviewed who suffered serious tissue damage and subsequent complications as follows: (1) Resident #42 acquired an avoidable unstageable pressure ulcer to his coccyx without evidence of weekly skin assessments as ordered by the physician. The area to the coccyx was debrided and subsequently deteriorated, due to treatments for the wound that were not being completed consistently as ordered, and the wound became infected with bone palpable requiring negative-pressure wound therapy (wound vac) and antibiotic therapy; (2) Resident #03 acquired an in facility Stage III pressure ulcer to the right gluteus, and a Stage IV pressure ulcer to the coccyx resulting in hospitalization with [DIAGNOSES REDACTED]. Additionally, one (#60) of three residents was placed at risk for more than minimal harm that is not Immediate Jeopardy when Resident #60 acquired an unstageable pressure ulcer to the left heel in the facility without evidence the facility consistently completed wound treatments as ordered by the physician.