PAYSON, AZ – PAYSON CARE CENTER

PAYSON, AZ Staff fails to provide necessary wound treatment.

PAYSON CARE CENTER

107 EAST LONE PINE DRIVE
PAYSON, AZ

FACILITY FAILED TO PROVIDE APPROPRIATE PRESSURE ULCER CARE AND PREVENT NEW ULCERS FROM DEVELOPING

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.

State Findings:

Based on clinical record review, observation, staff interviews, and policy review, the facility failed to ensure one of three sample residents (#65) was provided necessary treatment and services consistent with professional standards of practice regarding pressure ulcers. The deficient practice could result in the development of pressure ulcers, wound complications and delayed identification of new skin issues.

An interview was conducted with a Registered Nurse (RN/staff #91) on (MONTH) 19, 2019 at 9:17 a.m. She stated that the nurse is to do a head to toe skin assessment within two hours of admission/re-admission and then weekly and as needed after that. She stated that if the resident is admitted with wounds the dressings should be adjusted enough to visualize and assess the wound unless there is a provider order to leave the dressing in place, the assessment/description of any wounds present should be documented in the admission nursing assessment, and the nurse should notify the wound nurse that the resident has wounds. She stated that if the wounds were present on admission/re-admission there should not be 4 to 5 days between admission/re-admission and documentation of wound assessments. She stated that a head to toe skin assessment completed over seven days from the prior assessment would be late.

An interview was conducted with the wound nurse (LPN/staff #96) on (MONTH) 19, 2019 at 1:05 p.m. She stated skin assessments are to be conducted weekly. The wound nurse stated that if weekly skin assessments are late, new skin issues may be missed and/or there could be a delay in notification and treatment of [REDACTED]. The wound nurse stated that the wound observation tool is done once a week and that she does the staging of wounds. She stated that the wound assessments on resident #65 did not meet expectation as there was no documentation of an assessment of the wounds until 4 and 5 days after the readmission. She stated that by not doing an initial assessment, they would not be able to identify if the wounds had changed or worsened.

During an interview conducted with the Director of Nursing (DON/staff #41) on (MONTH) 19, 2019 at 1:43 p.m., the DON stated the expectation is that the admission nurse completes the skin status which would include any wounds on the admission/readmission collection tool. She stated that the 4 and 5 day delay of wound assessments increased the risk of unidentified wound deterioration that could have been present on admission. She stated that the nursing staff is expected to do a head to toe skin assessment on admission and weekly thereafter. The DON further stated that the skin assessment conducted on (MONTH) 17, 2019 was late which could increase the risk of missing new skin issues.

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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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