State Findings:
Based on record review and interview, the facility failed to ensure that residents received care needed to identify and treat Pressure Ulcers (PUs) [bed sore, skin, and underlying tissue such as fat, muscle and bone, damage due to excess pressure, friction, or shear to the area] for 2 (R #21 and 22) of 2 (R #21 and 22) residents reviewed for facility acquired pressure ulcers, due to not ensuring systems were implemented to prevent the development of facility acquired PU, quickly recognize the development of a pressure related injury, assess it accurately and obtain treatment care orders from the appropriate providers. This deficient practice likely resulted in R #21 and R #22 developing unstageable pressure wounds (full thickness skin [all layers of skin is gone and the damage extends into fat tissue and often into muscle and bone below the fat layer]) and may have contributed to their deaths.
On [DATE] at 11:58 am, during an interview, R #21’s daughter, revealed, I picked her (the resident) up on Saturday [[DATE]], they (the resident and facility staff) were waiting outside when I got there, they (the facility staff) just put her (the resident) in the car and that was it. She revealed being aware that her mother had a wound, does not remember what date the facility told her about it, but that the wound was much worse than she thought. She reported, It (the wound) was the size of your hand with a big hole in the middle of it and it smelled bad. She (the resident) wasn’t the way she used to be, she was in a lot of pain, she was drinking one glass after the other of water. How can those workers (the facility staff) do that to her (the resident)? I knew she (the resident) wasn’t herself. I took her (the resident) to the hospital the next day.
Record review of documentation from the residents’ admission to acute care hospital after discharge from facility revealed:
On [DATE] at 10:45 pm, Emergency Department (ED) admission revealed, diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . She was admitted from the ED into the Intensive Care Unit.
On [DATE] at 3:23 am, provider admission History and Physical revealed Septic shock likely due to the sacral decubitus wound [PU].
On [DATE] at 4:45 pm, provider progress note revealed, [AGE] year-old woman presenting with .severe decubitus ulcer [PU], septic shock .Discussed with daughters, who have agreed that patient had suffered enough and would like to allow her to pass comfortably.
On [DATE] at 6:14 pm, discharge documentation revealed, Resident was declared deceased on [DATE] at 6:11 pm.
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Personal Note from NHA-Advocates
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