KINGSTON, PA – MANORCARE HEALTH SERVICES-KINGSTON

Based on review of clinical records, observations and staff interviews it was revealed that the facility failed to timely identify and address declines in skin integrity to prevent the development and/or worsening of a pressure sore (injury to skin and underlying tissue resulting from prolonged pressure or friction on the skin) by one of one resident reviewed (Resident 134).

Review of nursing documentation dated (MONTH) 3, 2019, at 12:51 PM revealed that the resident had a decline in health and the physician wanted the resident transferred to the hospital. Further review of documentation on this date revealed that the resident was admitted to the hospital due to infection, failure to thrive and a pressure ulcer.

Review of nursing documentation on (MONTH) 9, 2019, at 4:32 PM indicated the resident was readmitted to the facility and the physician would like the resident to be turned every two hours due to the resident’s pressure ulcer.

Observation on (MONTH) 14, 2019, at 9:52 AM revealed the resident was lying in her bed, on her back. The resident’s Broda chair (a chair to correct positioning to provide improved independence and quality of life) was against the wall with no pressure relieving device on the chair.

An observation on (MONTH) 14, 2019, at approximately 1:00 PM revealed the resident remained in bed positioned on her back as observed at 9:52 AM. No pressure relieving device was seen in the room for her Broda chair.

An interview with Employee 2, Registered Nurse Quality Consultant, on (MONTH) 14, 2019, at approximately 1:30 PM revealed that the facility does not document repositioning of residents. Therefore the facility was unable to demonstrate that the resident was turned and repositioned at the frequency required to prevent worsening of the pressure sore and that the resident was turned and repositioned every two hours as directed by the physician on (MONTH) 9, 2019. Employee 2 stated that you can see the resident is being moved when she is toileted.

An observation on (MONTH) 14, 2019, at 2:05 PM revealed that the resident was lying on her right side in bed.

An interview with Employee 1 LPN (license practical nurse) confirmed there was no pressure relieving device in the room for her the resident’s Broda chair. Employee 1 stated that he did not know if she gets it anymore. Employ 1 further stated that the resident only gets out of bed for meals that she needs assistance.

The facility was unable to demonstrate that they had timely identified declines in skin integrity and had implemented prompt and adequate measures to prevent the worsening of a pressure sore on the resident’s sacrum and left buttock for a resident identified as a high risk for pressure sore development upon admission to the facility on (MONTH) 13, 2019.