State Findings:
Based on observation, interview, and record review, the facility failed to provide the necessary treatment and services to promote healing, prevent infection, and prevent new ulcers from developing for 3 of 10 (CR#1, CR#2 and Resident #4) reviewed for pressure ulcers in that:
The facility failed to put preventative measures in place to prevent pressure ulcer development for CR #1 after she was identified as high risk of developing pressure ulcers. Facility staff were not routinely repositioning or bathing CR #1. She developed a necrotic Stage IV pressure ulcer on her left buttock and a necrotic Stage IV DTI wound on her left ankle in the facility.
The facility failed to assess and care for CR #1’s wounds effectively. She was admitted to the hospital with [REDACTED]. The facility failed to ensure CR #1’s skin was kept clean and dry and ensure she was bathed routinely. CR #1 was admitted to the hospital with [REDACTED].
The facility delayed putting interventions in place and failed to assess CR #2’s wound to left lateral ankle to ensure the wound did not worsen.
The facility failed to put preventative measures in place for Resident #4. Who developed a stage II pressure ulcer in the facility.
-The facility failed to ensure the licensed staff providing wound care were knowledgeable and competent in the identification, assessment, documentation and treatment of [REDACTED].
The facility failed to ensure skin assessments were completed per the resident’s plan of care for CR #1, CR #2 and Resident #4.
An Immediate Jeopardy (IJ) was identified on 12/11/2018. While the IJ was removed on 12/13/2018, the facility remained out of compliance at a severity level of Actual harm that is not immediate jeopardy and a scope of pattern due to needing to train staff and monitor their implementation of the Plan to Remove the Immediate Jeopardy.
These failures affected 3 residents requiring one resident to be hospitalized and surgical rerouting of bowels and placed 2 additional residents at risk for worsening pressure ulcers, new pressure ulcers, infections and potential life-threatening complications.
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