TUCSON, AZ- PARK AVENUE HEALTH AND REHABILITATION CENTER

Based on clinical record review, staff interviews, and review of policy, the facility failed to ensure one resident (#3) was provided care and services, consistent with professional standards of practice, to prevent, treat and/or heal a pressure ulcer. The sample size was 3. The deficient practice could result in pain, worsening and/or infection of pressure ulcers.

Findings include:

Resident #3 admitted to the facility 09/28/22 with diagnoses including type 2 diabetes mellitus with diabetic peripheral angiopathy with gangrene, morbid (severe) obesity due to excess calories and quadriplegia.

A Skin/Wound Note dated 09/29/2022 12:02 included an initial visit with the resident. The note revealed that the resident has a Braden scale score of 15 [at risk for the development of pressure ulcers]. A healed stage 2 pressure injury with scarring was noted to the sacral area.

A physician ‘ s order dated 09/29/22 included to cleanse the denuded area on sacrum with soap and water. Apply Triad (triamcinolone/corticosteroid) hydrophilic cream twice daily, every day and evening shift.

Physician’s Order dated 10/14/22 included to cleanse the denuded area on sacrum with soap and water, apply Medi-honey (enzyme), adhesive foam, Change 3 times per week, every day shift on Monday, Wednesday and Friday.

On 10/19/2022 at 7:48 a.m. a Skin/Wound Note included that the resident was seen for wound rounds that morning. The note indicated the resident had MASD to his sacrum with skin loss. The note further identified the wound bed with some slough present along with pink granulation tissue, and stated the area was resolving. The physician ‘ s orders included continuing with Medihoney and Hydrogel, and to cover with an adhesive foam dressing change 3 x week.

However, a complete evaluation of the wound, including measurements and description of exudate and peri wound was not completed.

On 11/01/22 at 8:39 a.m. a Skin/Wound Note included that the resident’s family was notified that the denuded area to the resident ‘ s sacrum had not responded well to treatment. The note indicated that the resident was compliant with dressing changes, but at times non-compliant with repositioning. The note included that the current dressing was not assisting with drainage and that the order was changed to assist with drainage. The wound had developed an odor and eschar.  Provider notified.

A Wound assessment dated [DATE] at 5:20 p.m. revealed a sacral wound measuring 15 cm (centimeters) x 10 cm x UTD (unable to determine), moderate serous exudate, and odor. The note indicated that a drastic change to the wound bed, drainage and odor was identified. The note included that the provider had been notified and that the resident had been sent to the hospital.

Review of the Nurse Home to Hospital Transfer Form revealed the resident was sent to the ER related to an infected wound of the sacrum.

On 02/07/23 at 4:22 p.m. an interview was conducted with the wound care nurse (staff #43). She stated that the resident had been admitted to the facility with MASD to the sacrum. However, after review of her own admission progress note, she did not respond when asked if her documentation had correctly identified a healed stage 2 pressure ulcer with scarring to the resident’s sacrum. She stated that all of her wound assessments were listed under the IDT (Interdisciplinary Team)/Skin Meeting Notes. She stated that they do not use the weekly skin/wound templates in the facility. She stated that she will just describe the assessments in a progress note.

The Wound Management policy, revised 08/2022, included that a resident who enters the facility without pressure ulcers does not develop pressure ulcers unless the resident ‘ s clinical condition or other factors demonstrate that a developed pressure ulcer was unavoidable; and a resident having pressure ulcers receives necessary treatment and services to promote healing, prevent infection, and prevent new, avoidable sores from developing.