ALBUQUERQUE, NM- BEAR CANYON REHABILITATION CENTER

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 45426

Based on record review and interview, the facility failed to:
1. Provide oversight of shower sheets to identify wounds,
2. Accurately document new skin impairments on Skin Checks,
3. Update and implement new preventative measures, treatment, and orders when new skin impairments were identified for 1 (R #1) of 3 (R #1, 2, and 3) residents reviewed for pressure wound injuries. This deficient practice could like result in new pressure injuries, pain, or significant decline in health status.

The findings are:
A. Record review of R #1’s current electronic health record revealed R #1 was admitted to the facility on [DATE] with the following diagnoses:
– Polyosteoarthritis [five or more joints have arthritis (a painful inflammation and stiffness of the joints) at the same time],
– Age-related osteoporosis (a medical condition in which the bones become brittle and fragile from loss of tissue),
– Peripheral autonomic neuropathy (damage to the autonomic nervous system, which controls involuntary body functions such as heart rate, perspiration, blood pressure, digestion, loss of bladder control),
– Psoriasis (a skin disease that causes a rash with itchy, scaly patches).
– These diagnoses are not all-inclusive and do not include all of R #1’s diagnoses.

B. Record review of R #1’s Braden Scale for Predicting Pressure Score Risk (an assessment tool used to assess and document a resident’s risk for developing pressure injuries), dated [DATE], showed a score of 11, which indicated a high risk to acquire pressure sores.

C. Record review of R #1’s care plan, review date [DATE], revealed the following:

– R#1 required extensive assistance of one with bed mobility, changing, dressing, and personal hygiene.
– R#1 was at risk risk for skin breakdown related to decreased mobility, and frail fragile skin.
– Staff to implement the following interventions:
– Observe skin for signs and symptoms of skin breakdown, such as redness, cracking, blistering, decrease sensation, and skin that does not blanche (change to white color when pressure is applied) easily.
– Evaluate for any localized skin problems, such as dryness, redness, pustules, inflammation.
– Assist resident in turning and reposition every two hours.
– Pressure redistribution surface to bed, low air loss mattress (a mattresses designed to distribute the patient’s body weight over a broad surface area and help prevent skin breakdown.)
– The care plan did not contain interventions related to the resident’s refusals of nail care and scratching at wounds.

D. Record review of the facility policy, titled NSG236 Skin Integrity and Wound Mangement #6, revision date [DATE], stated, The licensed nurse will perform and document skin inspections .weekly .and with any significant change in condition.
E. Record review of R #1’s Skin Check forms, dated [DATE], revealed nursing staff documented the
following:
– On [DATE], the resident had new skin wounds. An open area to the resident’s right hip, an abrasion which measured approximately 1 inch (in) by 0.75 in; a scab to the resident’s anterior (palm) right hand, which measured 0.5 in by 0.5 in; and redness to the resident’s right antecubital space (the space inside the crook of the elbow).
– On [DATE], the resident had a previously identified skin wound initially thought to be from self-scratching will now be re-classified as unstageable pressure with new SWIFT (Swift technology – a digital program that visualizes and measures wounds accurately, and automatically tracks wound healing progression and management) photo, located at the right hip and right elbow. A skin tear/bruise was located at the right elbow.
F. Record review of R #1’s Skin and Wound Evaluations (an evaluation performed to document and
determine the appropriate treatment for a wound), dated [DATE], revealed staff documented the following:
– On [DATE], the resident had a front right hip abrasion which measured 2.52 cm (centimeters) long, 3.37 cm wide.
– On [DATE], the resident had a front right hip wound which measured 1.9 cm length, 3.0 cm width.

– On [DATE], the resident had a right hip wound reclassified as pressure injury, unstageable [a full-thickness injury in which the base of the wound is obscured by slough (dead tissue, usually cream or yellow in color) or eschar (dry, black, hard dead tissue)].
G. Record review of R #1’s Skin Check forms (a medical form used to track and assess skin issues and conditions), dated [DATE], revealed nursing staff documented the following:
– On [DATE], the resident had a Stage 3 pressure ulcer (a pressure sore that has full thickness tissue loss, subcutaneous fat may be visible, but bone, tendon, or muscle is not exposed) located on the right hip; A skin tear/bruise located at the right elbow.
– On [DATE], the resident had a Stage 3 pressure ulcer on the right hip; and a skin tear/bruise located at the right elbow.
– On [DATE], the resident had a Stage 3 pressure ulcer on the right hip; and a skin tear/bruise located at the right elbow.
– On [DATE], the resident had a Stage 3 pressure ulcer on the right hip; and a skin tear/bruise located at the right elbow.

H. Record review of R #1’s Skin Assessment, dated [DATE], revealed staff documented the resident had a in-house acquired (wound developed after admission to a healthcare facility) right hip pressure wound, stage
3, full thickness skin loss, which measured 0 centimeter (cm) by 0 cm by 0 cm and classified as resolved. Staff noted a foam dressing was placed on the area for protection, and wound care orders were to be discontinued on [DATE].

I. Record review of R #1’s physician’s orders, dated [DATE], revealed the record did not contain orders for treatment for the hips, shoulder, or sacrum area after [DATE].
J. Record review of a physician progress note for R #1, dated [DATE], MD #1 indicated the Stage 3 pressure was healed and measured 0 cm by 0 cm, with no measurable depth and an area of 0 cm2.
K. Record review of R #1’s shower sheets, dated [DATE], staff documented the following:
– On[DATE], the resident had reddened areas and an open area on R #1’s hips, scratches on R #1’s lower back, and the resident refused nail care.
– On [DATE], the resident had reddened areas, an open area, and a darkened area on both of R #1’s hips, scratches on R #1’s lower back, and the resident refused nail care.
– On [DATE], the resident had reddened areas and an open area on R #1’s hips, a wound on the lower back, and the resident needed nail care but refused. The staff also documented that R #1 takes off dressings.
L. Record review of R #1’s Skin Check forms, dated [DATE], revealed the following:
– On [DATE], a resolved Stage 3 pressure ulcer on the right hip was identified. Staff did not document any other skin impairments.

– On [DATE], a resolved Stage 3 pressure ulcer on the right hip was identified. Staff did not document any other skin impairments.
– On [DATE], a resolved Stage 3 pressure ulcer on the right hip was identified. Staff did not document any other skin impairments.
M. Record review of R #1’s Skin and Wound Evaluations revealed staff documented the following:
– The record did not contain skin and wound evaluations between [DATE] to [DATE].
– On [DATE], the resident had a right shoulder, blister which measured 1.89 cm by 0.89 cm.
– On [DATE], the resident had a right shoulder Stage 2 pressure ulcer (an ulcer that has a break in the top two layers of skin, usually open with swelling, discoloration, and pain), which measured 1.63 cm by 1.22 cm.
– On [DATE], the resident had a sacrum wound, which was unstageable, with slough and/or eschar, and measured 5.7 cm by 3.3 cm, Staff noted the following interventions: foam dressing, mattress with pump, pillows, repositioning every one to two hours, practitioner notified.
– On [DATE], the resident had a unstageable sacrum (the large, triangular bone at the base of the spine) wound, which measured 6.04 cm by 3.07 cm.
– On [DATE], the resident had a front left hip, unstageable, deep tissue injury (DTI; persistent non-blanchable deep red, purple, or maroon areas of intact skin, non-intact skin, or blood-filled blisters caused by damage to the underlying soft tissues), unstageable, which measured 3.04 cm length by 3.21 cm. Applied betadine foam (a type of antiseptic).
– On [DATE], the resident had a front left hip, unstageable pressure ulcer, slough and/or eschar, which measured 3.24 cm by 2.93 cm.
– On [DATE], the resident had an unstageable front right hip pressure wound which measured 6.56 cm by 4. 85 cm.
– On [DATE], the resident had an unstageable front right hip wound, new, in-house acquired, which measured 8 cm length, 8.9 cm width, with full thickness skin and tissue loss, 100% of the wound is eschar filled, redness, inflammation, warmth, light exudate (a fluid released by a wound), serosanguineous (drainage containing blood), no odor after cleansing.
N. Record review of R #1’s physician’s orders for R #1 revealed the following:
– The record did not contain orders for treatment for the hips, shoulder, or sacrum area after [DATE] through [DATE].

– A wound care order, start date [DATE], for unstageable pressure ulcer of the sacrum. Cleanse the wound with Vashe (name brand of a type of a saline based wound cleanser), paint the area around the wound with Betadine (a type of a topical antiseptic that provides infection protection), apply a skin layer of Therahoney (wound healing ointment), cover with Calcium Alginate (wound dressing), and cover the wound with foam dressing. Every day shift and as needed.
– A wound care order, start date of [DATE], for unstageable pressure ulcer of the right hip. Cleans the wound with wound cleanser or Vashe, skin prep (a liquid film-forming dressing that, upon application to intact skin, forms a protective film to help reduce friction during removal of tapes and films) to surrounding skin, and place a foam dressing saturated with Betadine over the wound. Every day shift and as needed if the dressing becomes wet, soiled or missing.
– A wound care order, start date of [DATE], for unstageable pressure ulcer of the left hip. Cleanse the wound with wound cleanser or Vashe, skin prep to surrounding skin, and place a foam dressing saturated with Betadine over the wound. Every day shift and as needed if the dressing becomes wet, soiled, or missing.
– A wound care order, start date of [DATE], for a blister located on the right shoulder. Clean with Vashe, paint the wound with Betadine, skin prep to surrounding area, and cover with foam dressing for protection. Every day shift.
– A wound care order, start date of [DATE], to check dressings to right shoulder, bilateral hips, and sacrum to ensure they are intact. If not, provide wound care following as needed orders, every night shift.
– An order for doxycycline hyclate oral tablet (an antibiotic used to treat infections), 100 milligrams (mg). Give one tablet by mouth two times a day for wound infection for ten days.
O. Record review of R #1’s Treatment Administration Record (TAR), dated [DATE], revealed the following:
– Wound care unstageable pressure sacrum: Cleanse with wound cleanser or Vashe and pat dry. Paint intact peri-wound with Betadine. Apply thin layer of Therahoney to open area, then cover with Calcium Alginate. Skin prep to surrounding skin. Cover with foam dressing, every day shift for sacral pressure ulcer. Start Date
-[DATE] 6:00 am; discharge date -[DATE] 8:37 am. Staff administered the treatment on [DATE], [DATE], [DATE] and [DATE].
– Wound care unstageable pressure ulcer right hip: Cleanse with wound cleanser or Vashe and pat dry. Skin prep to surrounding skin. Place foam dressing saturated with Betadine over wound. Every day shift for right hip pressure ulcer. Start Date -[DATE] 6:00; discharge date -[DATE] 8:37 am. Staff administered the treatment on [DATE], [DATE], [DATE] and [DATE].
– Wound care unstageable pressure ulcer left hip: Cleanse with wound cleanser or Vashe and pat dry. Skin prep to surrounding skin. Place foam dressing saturated with Betadine over wound. Every day shift for left hip pressure ulcer. Start Date -[DATE] 6:00 am; discharge date -[DATE] 8:37 am. Staff administered the treatment on [DATE], [DATE], [DATE] and [DATE].

– Wound care blister right posterior shoulder: Cleanse with wound cleanser or Vashe and pat dry.
Generously paint with Betadine. Skin prep to surrounding skin. Cover with foam dressing for protection. As needed (PRN) for right shoulder blister. Start Date -[DATE] 6:15 pm; discharge date -[DATE] 8:37 am. Staff administered the treatment on [DATE], [DATE], [DATE] and [DATE].
– Staff to check dressings to right shoulder, bilateral hips, and sacrum to ensure they are intact. If not, provide wound care following night (pm) orders. Every night shift for right shoulder, bilateral hips, and sacrum. Start Date -[DATE] 6:00 pm; discharge date -[DATE] 8:37 am. Staff administered the treatment on [DATE],
[DATE], [DATE] and [DATE].
– Doxycycline hyclate oral tablet, 100 mg. Give 1 tablet by mouth two times a day for wound infection for ten days. Start Date -[DATE] 8:00 pm; discharge date -[DATE] 8:37 am. Staff administered the medication on [DATE], [DATE], [DATE].
P. Record review of R #1’s nursing progress notes revealed the following:
– On [DATE], facility staff notified the on-call provider that R #1 had symptoms of infection in the right hip. A physician’s order for Doxycycline (an antibiotic used to treat infections), 100 mg, twice a day was received.
– On [DATE] 6:27 pm, staff documented the resident’s vitals as: blood pressure ,d+[DATE] (normal less than or equal to ,d+[DATE]) , pulse 94 (normal ,d+[DATE]), respiratory rate 16 (normal 12 to 18), temperature 99. 7 (normal 97 to 99), pulse oximetry [a test used to measure the oxygen level (oxygen saturation) of the blood] 90 percent (%) (normal 95% to 100%).
– On [DATE], R #1 developed a wet cough, (a cough that produces mucus or phlegm).
– On [DATE] 7:41 am, staff documented the resident’s vitals as: blood pressure ,d+[DATE], pulse 87, respiratory rate 17.0, temperature 97.7, pulse oximetry 92.0%.
– On [DATE], R #1 had a change in condition of vital signs, with a pulse oximetry reading of oxygen 87%, altered levels of consciousness, and labored breathing. R #1 was transported to the emergency room .
Q. Record review of R #1’s hospital records, admitted [DATE], stated the following:
– The resident was admitted with diagnoses of:
– Severe sepsis (a serious infection usually caused when bacteria make toxins that cause the immune system to attack the body’s own organs and tissues).
– Decubitus ulcer (a pressure sore of damage to the skin and tissue underneath in the over the bony region of the very end of the spine) of coccyx.
– Decubitus ulcer of hip.
– Decubitus ulcer of shoulder blade. – Infection caused by multi-drug resistant bacteria.
– Decubitus ulcer with full thickness skin loss involving damage of subcutaneous (beneath, or under, all the layers of the skin) tissue of right hip.
– The list is not all inclusive and does not include all of R #1’s diagnoses.
-R #1 was admitted to the Intensive Care Unit for a septic (infected, or denoting infection) cough, secondary (relating to a medical condition that arises as a result of another disorder, disease process, or injury) to infected decubitus wounds. R #1 underwent incision and drainage [involves cutting and draining purulent (thick, white, and pus-like) contents from an abscess (a pocket of pus)] surgery of her right buttock and sacrum on [DATE]. Right hip and sacral eschars were removed. A culture of the sacral wound was positive for methicillin-sensitive staphylococcus aureus (MSSA; a type of infection, commonly known as a staph infection.) A culture of the fluid removed from R #1’s right hip abscess, on [DATE], revealed a heavy growth of staphylococcus aureus (group of spherical bacteria that causes infections).
– R #1 did not return to the facility. On [DATE], R #1 was admitted to Hospice. She expired on [DATE] at 6:50 am.
R. On [DATE] at 9:22 am, during an interview with the Wound Care Nurse (WCN), she stated she became aware of R #1’s wounds on [DATE] after the floor nurse alerted her. She said she was not aware of the resident’s wounds between [DATE] and [DATE], because there was not a physician’s order to treat them. She said R #1 had the original, right, front hip wound, a resolved Stage 3 pressure, which became unstageable; an unstageable to the sacrum; an unstageable to the left, front hip; and a right posterior (back) shoulder, Stage 2 pressure injury. The WCN stated she reassessed R #1’s wounds on [DATE] and saw redness around the right, front hip and the other wounds. She said all the wounds had eschar.
S. On [DATE] at 12:47 pm, during an interview, Certified Nursing Assistant (CNA) #1 reviewed and
confirmed she completed the shower sheets for R #1, dated [DATE], [DATE], [DATE], and [DATE]. She reported R #1 was getting red, and there were not treatment orders to address the areas of redness or the scratching. She stated R #1 would scratch at the sides of her hips and would remove the dressings that covered the wounds during the month of December. The CNA stated the wounds were scabbed and appeared to look like road rash, prior to healing. The scratched areas then would heal with a scab. The CNA reported R #1 would dig in her back with her long nails. She stated she spoke to the Assistant Director of Nursing (ADON) about her concerns for R #1, but she could not recall the date she reported it to the ADON.

The CNA stated one of R #1’s hip wounds healed, but then the wound came back. She reported the wound on R #1’s right hip was red and healed. The CNA did not recall when the resident’s left side got a wound but said it was red and started to become moist. She stated the wound on R #1’s back (sacral area) was dark and black. CNA #1 reported she was not aware of any wounds to R #1’s shoulder. She stated there was a mark on the resident’s shoulder that looked like a pimple, but it would not have been something she would mark on a shower sheet. 

T. On [DATE] at 2:27 pm, during an interview with Registered Nurse (RN) #1, she stated when a CNA finds a new wound on a resident, the nurse will assess the wound and talk about it with the WCN. RN#1 stated staff should document new areas of redness on the resident. RN #1 stated the wound on R #1’s right hip would bleed, and she would put a dressing on it. She said she did this maybe once or twice. She confirmed there were no orders for wound treatment for the resident’s right hip wound. She stated the orders for treatments for R #1’s right hip were discontinued on [DATE]. She stated R #1 needed orders for any treatments, and the WCN usually puts the orders into the resident’s medical record. RN #1 stated she asked the WCN to check on R #1’s right hip wound prior to going on leave on [DATE]. RN #1 did not remember seeing any scratches on R #1’s left hip. She stated she saw the wound on the resident’s back twice, and the wound was dark in the center with a scab and red outside the scab prior. The RN said she verberally reported this to the WCN prior to going on leave on [DATE].

U. On [DATE] at 9:15 am, during an interview, the ADON stated the process for identifying skin care issues for a resident included documenting on the shower sheet and communicating it to the nurse on the floor. He stated staff should document a change in condition (CIC; a sudden, clinically important deviation from a patient’s baseline, in physical, cognitive, behavioral, or functional domains). The ADON stated scratches and redness on hips were considered a change in condition, and staff should have created a change in condition record for R #1’s skin conditions that staff identified on the shower sheets on [DATE] and [DATE]. The ADON said changes in scabs and open areas are also considered a change in condition He said staff should document a CIC in the resident’s medical record, and the doctor will write an order for it. The ADON said CIC documents are reviewed by the unit manager, and staff also document it in a progress note. The ADON said the nurse who completed a CIC assessment was responsible to notify the provider. He said it did not have to be the WCN who notified the provider regarding CICs completed for a change in skin condition. The ADON stated R #1’s medical record did not contain skin assessments, documentation of a conversation, or progress notes regarding the skin concerns documented on R #1’s shower sheet dated [DATE]. The ADON confirmed he signed off on the shower sheets for R #1, dated [DATE], [DATE], [DATE], and [DATE]; and that indicated the shower task was completed. The ADON stated the CNA was then given direction to follow-up with the nurse.

V. On [DATE] at 9:41 am, during an interview, the WCN stated residents with scratches and scabs required skin assessments. She reviewed R #1’s shower sheets dated, [DATE], [DATE], [DATE], and [DATE]. She said she was not aware of the changes identified on the resident’s shower sheets, but staff should have made her aware, prior to [DATE]. The WCN stated staff can put foam dressing on the areas that are reddened and blanchable (when pressing an area of the body with a finger and releasing, the area should become pale and then return to its normal color). She said, if the area was opened, the granulation (the development of new tissue and blood vessels in a wound during the healing process) of the wound determined the type of protective dressing. She confirmed R #1’s medical record did not contain orders for any type of dressings, prior to [DATE]. The WCN stated she expected to see the wounds documented on skin checks, because she reviewed skin checks and not CIC documentation. She stated there was a problem with staff informing her about the wounds.

W. On [DATE] at 10:21 am, during an interview with the Director of Nursing (DON), she stated there was not a system to trigger change in condition for skin conditions documented on shower sheets that identified skin concerns. She stated new skin concerns were triggered by the skin check sheets. The DON stated if there was something new on the skin check then the WCN would do an assessment, but if the skin concern was not new then a skin assessment would not be triggered. The DON said the nurses address the skin check concerns the next day and create a CIC document for the skin concerns. The DON reviewed R #1’s shower sheets for December, 2023 and stated the CNA should have alerted the WCN. The DON stated staff should have documented the new wound areas on the resident’s skin checks. The DON stated R #1’s skin checks stated right hip, which suggested there was a current injury to that area. She said the WCN would need to follow-up on that documentation. The DON stated there was a breakdown in communication.