State Findings:
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Complaint # (AR 595) was substantiated, all or in part, with these findings:
Based on observation, record review, and interview, the facility failed to ensure necessary treatment and services were provided for management of existing pressure ulcers, as evidenced by failure to ensure pressure ulcer assessments, including measurements, staging and descriptions, were conducted and documented at least weekly, to ensure deterioration of the wound was promptly identified and addressed; failure to ensure the physician was immediately consulted regarding deterioration of pressure ulcers or an increase in the number of pressure ulcers; failure to ensure physician-ordered pressure ulcer treatments were consistently provided and documented at the frequency ordered by the physician to promote healing and prevent potential infection for 2 (Residents #2 and #3) and failure to ensure a pressure ulcer dressing was promptly replaced after being removed for a shower, to prevent potential infection or deterioration for 1 (Resident #3) of 2 (Residents #2 and #3) case mix residents who had pressure ulcers. The failed practices resulted in a pattern of actual harm for Residents #2 and #3, whose pressure ulcers were not consistently assessed and treated, after which they deteriorated, failed to improve and / or increased in number, and had the potential to cause more than minimal harm for 7 residents who had pressure ulcers, according to a list provided by the Administrator on 2/15/19.
On 2/14/19 at 2:43 p.m., the Director of Nursing (DON) was asked if she was aware there was a problem with treatments and wound documentation. She stated, No. I had no idea. We thought (LPN #1) would be so good doing the MDS that we pulled her and put her there. We hired a Treatment Nurse, but in the meantime, the nurses on the floor had to do their own treatments. I have started monitoring the treatments and documentation now to make sure it gets done. The DON was asked to provide any documentation that would show the treatments or wound assessments had been completed. As of 2/13/19 at 4:00 p.m., no documentation was provided
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NHAA is here to assist families, residents, and the community by sounding the alarm on issues like those found above. This nursing home and many others across the country are cited for abuse and neglect.
If you have or had a loved one living in this nursing home or any other nursing home where you suspect any form of abuse or neglect, contact us immediately.
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Personal Note from NHA-Advocates
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