HOUSTON, TX- AFTON OAKS NURSING CENTER

Based on observation, interview, and record review, the facility failed to ensure residents with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing for 2 of 10 residents (Resident #1 and Resident #2) reviewed for pressure ulcers.

The facility failed to provide daily wound care treatments for Resident #1 and Resident #2 as ordered by their physicians.

This failure could place residents with skin breakdown at risk of further skin injury and infection.

Record review of Resident #1’s care plan, revised on 11/14/2022 revealed he was on antibiotic therapy due to a wound infection until 11/10/2022 (Goal: The resident will be free of any discomfort or adverse side effects of antibiotic therapy. Interventions: Administer antibiotic medications as ordered and observe side effects); he has stage 4 pressure ulcers to the sacrum, left lateral ischium, right posterior lateral heel, left posterior heel, right lateral foot, left lateral ankle and an unstageable wound to the right ischium (Goal: The resident’s pressure ulcers will show signs of healing and remain free from infection. Interventions: Administer treatment as ordered and monitor for effectiveness, refer to wound physician as ordered, assess/record/monitor wound healing, assess, and document status of wound perimeter, follow facility policies/protocols for the prevention/treatment of skin breakdown, monitor nutritional status, obtain and monitor lab/diagnostic work as ordered, treat pain as ordered, and supplemental protein, amino acids,
vitamins, minerals as ordered).

Observation and interview with Resident #1 on 02/23/2023 at 9:10 a.m. revealed he was awake in bed on an air mattress. Resident #1 was alert and oriented to person, place, time, and happenings. Resident #1 stated he was admitted to the facility with wounds to his back side and to both feet. He said Treatment LVN A had already changed his dressings for the day, and he did not want to take the dressings off again for wound observation. He stated his wound dressings were being changed daily except on Mondays. Resident #1 said on the days his dressings were not changed, the nurses told him they did not have time to do wound care, or they did not have enough help.

Cleanse left ischium wound with wound cleanser, apply SilvaKollagen Gel and calcium alginate, cover with dry dressing daily, every day shift for wound care. Order Date- 01/26/2023. D/C date- 02/13/2023. Monday, 02/06/2023 was blank (indicating the treatment was not completed that day).

Cleanse left ischium wound with wound cleanser, apply SilvaKollagen Gel then calcium alginate, cover with dry dressing daily, every day shift for wound care. Order Date- 02/15/2023. Monday, 02/20/2023 and Tuesday, 02/21/2023 were blank (indicating the treatment was not completed on those days).

Cleanse right heel wound with wound cleanser, apply SilvaKollagen Gel then calcium alginate, cover with dry dressing daily, every day shift for wound care. Order Date- 01/26/2023. D/C date- 02/13/2023. Monday, 02/06/2023 was blank (indicating the treatment was not completed that day).

Cleanse right heel wound with wound cleanser, apply SilvaKollagen Gel then calcium alginate, cover with dry dressing daily, every day shift for wound care. Order Date- 02/15/2023. Monday, 02/20/2023 and Tuesday, 02/21/2023 were blank (indicating the treatment was not completed on those days).

Cleanse right medial ankle wound with wound cleanser, apply SilvaKollagen Gel then calcium alginate, cover with dry dressing daily, every day shift for wound care. Order Date- 01/26/2023. D/C date- 02/13/2023. Monday, 02/06/2023 was blank (indicating the treatment was not completed that day).

Cleanse right medial ankle wound with wound cleanser, apply SilvaKollagen Gel then calcium alginate, cover with dry dressing daily, every day shift for wound care. Order Date- 02/15/2023. Monday, 02/20/2023 and Tuesday, 02/21/2023 were blank (indicating the treatment was not completed on those days).

Cleanse sacral wound with wound cleanser, apply SilvaKollagen Gel then calcium alginate, cover with dry dressing daily, every day shift for wound care. Order Date- 02/15/2023. Monday, 02/20/2023 and Tuesday, 02/21/2023 were blank (indication the treatment was not completed on those days).

Collagen Hydrolysate (Bovine) Powder. Apply to right ischium topically every day shift for wound care. Cleanse right ischium wound with wound cleanser, apply collagen powder, cover with dry dressing daily. Order Date- 02/15/2023. Monday 02/20/2023 and Tuesday, 02/21/2023 were blank (indicating the treatment was not completed on those days).

Collagen Matrix (Bovine) 5x5cm. Apply to left heel topically every day shift for wound care. Cleanse left heel wound with wound cleanser, apply collagen powder/sheet and calcium alginate, cover with dry dressing daily. Order Date- 12/18/2022. D/C Date- 02/08/2023. Monday, 02/06/2023 was blank (indicating the treatment was not completed on that day).

Collagen Matrix (Bovine) 5x5cm. Apply to right ischium topically every day shift for wound care. Cleanse left heel wound with wound cleanser, apply collagen powder/sheet and calcium alginate, cover with dry dressing daily. Order Date- 12/18/2022. D/C Date- 02/13/2023. Monday, 02/06/2023 was blank (indicating the treatment was not completed on that day).

Collagen Matrix (Bovine) 5x5cm. Apply to sacrum topically every day shift for wound care. Cleanse sacral wound with wound cleanser, apply collagen powder/sheet and calcium alginate, cover with dry dressing daily. Order Date- 12/18/2022. D/C Date- 02/13/2023. Monday, 02/06/2023 was blank (indicating the treatment was not completed on that day).

In an interview with Charge Nurse B on 02/23/2023 at 1:45 p.m., she stated the facility had a full-time treatment nurse when she was hired in October 2022. Charge Nurse B said the treatment nurse worked on weekends and several other days during the week. She said she completed wound care treatments on her assigned hall when Treatment LVN A was not there. She said the DON also did wound care. Charge Nurse B said when Resident #1 got up before lunch, the DON did his wound care because she (Charge Nurse B) had to pass medications and could not do wounds and medications. Charge Nurse B said if Resident #1 wanted his wounds done between 2:00 p.m. and 10:00 p.m. (Charge Nurse B worked from 6:00 a.m. until 6:00 p.m.), she (Charge Nurse B) could do them. She said she had been the charge nurse on Resident #1’s hall all week since Monday, 02/20/2023. Charge Nurse B said she was not the wound care nurse and doing wound care was not in her job description, so when she could get to Resident #1, she did his wounds. She said when Resident #1 could not wait on her, then he just got up without wound care. Charge Nurse B said it
was not her job to do wound care and those (doing resident wound care) were extra. Charge Nurse B said wound care was not on her agenda Monday, 02/20/2023 or Tuesday, 02/21/2023. She said she did not complete any of the 7-8 wounds on her hall on Monday, 02/20/2023 or Tuesday, 02/21/2023 and she did not communicate with the DON to let her know wound care had not been completed. Charge Nurse B said when she did wound care, she documented the treatments in each resident’s TAR. She said she knew the treatment nurse worked on Wednesdays and on weekends, but she did not keep up with everybody’s schedules. She said she did wounds at her own leisure when they needed to be done. She said if the treatment nurse was not there, the DON did wound care. Charge Nurse B said the only time she did Resident #1’s wound care was when he wanted it done between 2:00 p.m. and 10:00 p.m. She said the DON never told her it was her (Charge Nurse B) responsibility to do wound care when the treatment nurse was not there (even though Charge Nurse B already said she did wound care when the treatment nurse was not there earlier in the interview). She said she did not know whose responsibility wound care was when the treatment nurse was not there, but it was not hers. Charge Nurse B said she had previously worked as a
treatment nurse, and she knew how important it was for residents to receive wound care every day the physician’s order was in place. She said if wound care was not completed daily, a resident could experience infection and death. Charge Nurse B said if the wound care treatment was easy or she could do it during a diaper change, she did the treatment, but she could not take three hours out of her day to do wounds with her other responsibilities. Charge Nurse B said again that wound care was not her job.

In an interview with the DON on 02/23/2023 at 1:25 p.m., she stated blanks on a resident’s TAR indicated someone forgot to sign for the treatment, or someone did not do the treatment. She said the facility was looking to hire a full-time treatment nurse and one of the unit managers just started that role on 02/21/2023. The DON said she (the DON) or the charge nurses should do wound care on the days the treatment nurse was not in the building. The DON said she instructed the nurses to do wound care for their assigned residents when the treatment nurse was not there unless she informed them (the nurses), she (the DON) would do them. She said the only way she would have known wound care had not been done was if she went behind the nurses to check. The DON said she did not check the residents’ TARs to ensure wound care had been done. The DON said Charge Nurse B was assigned to Resident #1 on the days his TAR was blank, and she should have completed his wound care on those days.