GILMER, TX – FOCUSED CARE OF GILMER

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, interview, and record review, the facility failed to provide care, consistent with professional standards of practice and based on a comprehensive assessment, to promote healing, prevent infection and prevent the development of new pressure injuries for 1 of 7 residents reviewed for pressure injuries. (Resident #3)

The facility did not implement pressure redistribution and dietary interventions to prevent Resident #3 from developing a facility acquired coccyx wound that worsened to a stage 3 pressure injury and 2 facility acquired pressure injuries on her buttocks. Resident #3 did not receive wound care as ordered.

This failure could place residents with pressure injuries at risk for development of new pressure injuries and the decline in existing pressure injuries.

During an interview on 01/17/19 at 3:31 p.m., the DON said if there was an open area with depth over a boney area it was a pressure injury. She said when she was made aware of a resident having a wound she looked at the area for herself and determine if the wound was a pressure injury. The DON said upon identifying a wound she would expect the physician to be notified and an order for [REDACTED].

During an interview on 01/18/19 at 11:08 a.m., the DON said she expected the physician, DON, family and the administrator to be notified of skin issues. She said an order should be obtained, initiated, and a referral should be made to the wound care physician as soon as possible. The DON said the dietician should be notified as well even if the resident received hospice services.