LOUISVILLE, KY – KLONDIKE CENTER

Based on observation, record review, and interview it was determined the facility failed to ensure that a resident who acquired a pressure sore on the foot received proper treatment to facilitate wound healing and not worsening of the wound for one (1) resident out of the thirty-seven (37) sampled residents. Resident #10 had a blistered on the right heel that had worsened and an unidentified pressure area on the bottom of the left foot under the little toe.

Interview with the Wound Nurse, on 09/06/19 at 4:45 PM, revealed the right heel was necrotic and unstageable. She further revealed the boots were dirty and needed to be changed. The wound nurse revealed a skin assessment monitoring sheet should have been started for the right heel and the left foot in order to monitor if the areas were worsening and the healing process. She revealed after reviewing the clinical record for Resident #10 that no skin assessment monitoring sheet had been started, the physician had not been notified, and there was no treatment obtained for the areas. She further revealed she did not see any documentation that the family had been notified of the areas and they should have been. The wound nurse further revealed the documentation should include what the pressure area looked like, the size and a skin monitoring sheet should have been started with that information documented on it. She revealed Resident #10 was at risk for infection and could loose his foot. She revealed a care plan should have been initiated for the right heel and the left foot and he/she should have clean boots.

Interview, on 09/06/19 at 4:45 PM, with Resident #10 revealed he had not gotten any clean boots put on since this surveyor had been in the room earlier with RN #1.