WINNSBORO, TX – WHISPERING PINES NURSING AND REHAB

Based on observation, interview, and record review, the facility failed to provide the necessary treatment and services, based on the comprehensive assessment and consistent with professional standards of practice, to prevent development of pressure injuries for 5 of 5 residents reviewed for pressure injuries. (Resident #s201, 48, 16, 33, and 49)

The facility did not complete weekly skin assessments for Resident #201 as ordered by the physician and did not notify the physician when the resident developed a DTI on her left heel. The facility did not provide interventions when Resident #201’s stage 3 pressure injury to the sacrum worsened and developed infection. The wound had signs and symptoms of infection for 17 days before the facility sent Resident #201 to the hospital where she was diagnosed with [REDACTED]. The resident was admitted to inpatient hospice and died in the hospital.

The facility did not implement interventions to promote healing and prevent infection of a stage 4 pressure injury to the sacrum of Resident #48 and prevent the development of a new stage 2 pressure injury to her left thumb. The facility did not position the resident off her back, stage and receive orders for treatment of [REDACTED].

The facility did not implement interventions to prevent the development of two new pressure injuries to Resident #33’s left elbow and left knee. The facility did not reposition the resident and keep her off bony prominences as indicated by her care plan. The staff did not know the correct settings for Resident #33’s low air loss mattress according to her weight.

The facility did not assess Resident #49’s skin regularly, identify new pressure injuries and implement interventions to prevent pressure injury development as care planned. CNA [NAME] did not report an open area on Resident #49’s bottom to the nurse and did not apply barrier cream after an incontinent episode.

The facility did not address interventions in Resident #16’s care plan to promote the healing and prevent worsening of a stage 3 pressure injury to her sacrum.

An Immediate Jeopardy (IJ) situation was identified on [DATE]. While the IJ was removed on [DATE] at 5:20 p.m., the facility remained out of compliance at a pattern of actual harm due to the facility’s need to complete in-service training and evaluate the effectiveness of corrective systems.

This failure could place residents who were at risk for pressure injuries and had pressure injuries at risk for development or worsening of existing pressure injuries, wound infections and death.

A hospitalist progress note dated [DATE] indicated Resident #201 was admitted to the hospital on [DATE] for clearance for outpatient surgical debridement of sacral ulcer. The note indicated the resident presented on a stretcher screaming in pain and was severely demented. The note indicated she was frail and cachectic (general ill health with emaciation), was in distress and had a smell of necrotic (death of tissue) flesh with purulent (containing pus) exudate (a fluid) oozing from her sacrum. The noted indicated Resident #201 had a stage 4 sacral ulcer to the bone with bubbles and exudate that was spontaneously dripping all over the hospital bed. The assessment and plan in the note indicated Resident #1 [MEDICAL CONDITION], a stage 4 sacral pressure injury with gas gangrene (death of body tissue due to either lack of blood flow or a serious bacterial infection), [MEDICAL CONDITION](high heart rate), severe dementia, debility with contractures, acute kidney injury, stage ,[DATE] [MEDICAL CONDITION], and severe protein calorie malnutrition.