State Findings:
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to ensure four Residents (R#7, R #26, R #66 and R#56) of 22 residents reviewed for pressure ulcers received the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing.
1) R#7 developed avoidable ulcers (one stage III pressure ulcer, four Stage II pressure ulcers, an unstageable pressure injury, and a deep tissue injury). The facility failed to provide timely off-loading of pressure areas and repositioning in accordance with the care plan. The facility also failed to know and implement manufacturer’s recommendations for R#7’s specialty mattress.
2.) The facility did not provide R #26, who was identified at risk for pressure ulcer development, with timely off-loading or repositioning, allowing her to have continuous pressure to her buttocks/sacrum/coccyx. R #26 had constant pressure to her buttocks for over seven hours and was not checked or changed for incontinence for over five hours. Staff did not apply skin barrier cream on R #26 after incontinent care was provided, to protect the skin from irritation and breakdown, as indicated in her care plan.
3.) The facility did not provide R #66, who was identified at high risk for pressure ulcer development, with timely off-loading or repositioning, allowing her to have continuous pressure to her buttocks/sacrum/coccyx. R #26 had constant pressure to her buttocks for over seven hours and was not checked or changed for incontinence for over five hours.
4.)The facility failed to accurately identify and document R#56’s Left and right buttock facility acquired pressure ulcer & staged and documented the ulcer as an unstageable despite the description of an ulcer meeting a stage 2. The Facility staff failed to document and report the stage of the wound accurately, the wound care treatment may not be appropriate for the wound.
-Registered Nurse (RN) J failed to follow R#56’s physician orders [REDACTED].#56’s pressure ulcer wound care.
These failures had the potential to affect residents by placing them at risk for infection and the development and worsening of pressure ulcers.
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