State Findings:
The facility failed to prevent the development of multiple avoidable pressure sores for one resident. Resident #1 was ordered a stabilizing low boot on 1/18/22 related to a fracture resulting from a fall. From 1/18/22 to 2/18/22 the boot was never removed to assess skin. On 2/28/22 Resident # 1 was identified with an unstageable wound t an area covered by the low boot. On 3/1/22 the wound was identified as a stage 3. On 3/14/22 the family requested the resident be sent to the hospital related to the worsening of the wound and two wounds were assessed as a stage 4 wound and an unstageable wound.
Record review of Hospital Narrative Notes Details by PT dated 3/14/22 at 3:36 PM….Notes: Patient was evaluated today for wounds to her R lower leg. Inspection of the area revealed obvious deformity and x-ray confirm a non-healing tib/fib fracture. The patient sustained this fracture in January and was placed in a low boot. She has a larger open ulceration to the Right lateral lower leg which is quite deep and is concerning for [CONDITION(S)] (inflammation or swelling that occurs in the bone). On the opposite side of the leg at the level of the fracture, there is discoloration consistent with a Deep Tissue Injury. These are likely a result of sustained pressure from the boot the patient was previously wearing.
During an interview on 3/16/22 at 2:15 PM, the DON, stated no one took the boot off. She stated the orders were to reposition the boot. She stated they did not learn about the wound until 2/28/22 when a LVN was assessing the boot and got some blood on her finger. She stated that no one took the boot off from 1/18/22 to 2/28/22. She stated she did not think about removing the boot even for a small time to do a skin assessment. DON stated she never reached out to Dr. D and assumed the boot was never to be removed at all.
Record review of Consultation on 3/14/22 at 8:50 PM by Dr. E: ….Plan: Basically, this is not anything that we are going to be able to salvage with her overall condition. I think the options are pretty simple, we can either do a primary amputation and remove the leg, probably a below-knee amputation wound suffices on her or she could just manage with open wound care and hospice and figuring that this thing will go on and continue to break down probably get infected and she could eventually get septic and could die from that.
Resident #1 had leg amputated below knee on 3/18/22.
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