SCRANTON, PA – THE GARDENS AT SCRANTON

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

Based on review of clinical records and staff interview, it was determined that the facility failed to consistently implement interventions designed to prevent pressure sore development, prevent worsening and promote optimal healing for one of 10 residents reviewed (Resident 55) with pressure sores.

Further review of nursing documentation and a pressure ulcer investigation tool dated (MONTH) 25, 2019, revealed that Resident 55 was at risk for pressure sore development and had impaired transfer and bed mobility. The documentation noted that this resident had refused repositioning during the past month. However, a review of nursing documentation for the month of (MONTH) 2019 conducted at the time of the survey ending (MONTH) 15, 2019, revealed no documented evidence that the resident had refused turning and repositioning prior to the (MONTH) 25, 2019, discovery of the pressure sores.

A review of a hospital discharge summary dated (MONTH) 1, 2019, indicated that Resident 55 was admitted to the hospital with [REDACTED]. While a patient at the hospital, Resident 55 had a surgical consult for a sacral wound. The hospital found that the resident had a gangrenous (localized death and decomposition of body tissue, resulting from either obstructed circulation or bacterial infection) decubitus ulcer (pressure sore), Stage IV. The surgical consult recommended surgical debridement of the area and a diverting [MEDICAL CONDITION] (a surgical procedure to create a [MEDICAL CONDITION], for external bowel movements, in which a bag is placed on the outside of the abdomen to collect feces. This was done so this resident would have no fecal matter in his sacral wound to prevent further decline and infection). A wound vac (also referred to as a negative pressure wound therapy is a machine used to treat advanced bed sores. A wound vac uses a pump to suction fluids from bed sores or other wounds that are difficult to heal on their own) was placed on this resident to promote healing.