State Findings:
Based on observation, interview, and record review the facility failed to provide care and services, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers for 3 of 19 residents (Residents #39, #52, and #50) reviewed for pressure ulcers.
-Facility staff failed to reposition Resident #39 who had a necrotic pressure ulcer.
-The facility failed to reposition Resident #52.
-The Wound Care Nurse failed to provide incontinent care after she removed saturated incontinent brief and before providing wound care for Resident #50.
These failures affected 3 residents and placed 10 residents with pressure ulcers at risk for developing new pressure ulcers or a decline in existing pressure ulcers.
Observation on 08/17/18 at 9:25 a.m., wound care observed on revealed that Resident 50’s brief was saturated with urine. The draw sheet and mattress were soaked. When the wound care nurse removed the brief, the surveyor asked the wound care nurse to squeeze the brief and she stated that it was saturated. The Wound Care Nurse did wound care without providing incontinent care. She cleaned the wound bed and did not did not clean the peri area of the wound. Then she applied calcium alginate on the three wound sites and used skin prep to wipe around the alginate and applied boarded foam dressing. then she positioned the resident on her back on the wet draw sheet that was wet with urine. Interview on 08/17/18 at 9:35 a.m., Wound Care Nurse stated, oh I see why incontinent care would have been done before doing the wound care. she stated that she did not clean the peri wound, but the order was to clean the wound. She stated that she laid the resident back on the wet draw sheet while the CNA brings a clean sheet.
The facility’s Centers for Medicare and Medicaid Services (CMS) Form 672 dated 08/14/18 identified 13 residents with pressure ulcers.
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