OLYPHANT, PA- AVENTURA AT TERRACE VIEW

The Department of Health & Human Services conducted an inspection of the facility. The following decencies listed below were found in a public survey.

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 48277

Based on a review of clinical records and incident reports, observations and staff interview it was determined that the facility failed to timely identify and act upon changes in skin integrity, promptly assess and treat pressure sores and consistently implement interventions to prevent pressure sore development resulting in two facility acquired pressure sores, a Stage 3 sacral wound and unstageable pressure sores on the resident’s foot, for one resident out of five sampled (Resident 23).

Findings included:

Review of Resident 23’s clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses of unspecified dementia (a group of symptoms that affects memory, thinking and interferes with daily life), and kidney disease.

Review of Resident 23’s Annual Minimum Data Set Assessment (MDS- a federally mandated standardized assessment process conducted periodically to plan resident care) dated October 5, 2023, revealed that the resident had a moderate cognitive impairment, required moderate assistance for rolling in bed, was totally dependent for toileting, bathing, dressing, and transfers, was at-risk for developing pressure ulcers and injuries, and was always incontinent of bowel and bladder.

Review of Resident 23’s care plan, revised October 5, 2023, revealed that the resident had the potential for skin breakdown due to decreased mobility and incontinence. Planned interventions were the application of a barrier cream every shift, and as needed, for incontinency, dietary supplements as per MD order, encourage the resident to reposition side to side in bed (the resident’s MDS 10/5/23 indicated that the resident required moderate staff assistance with rolling in bed), observe skin condition daily during care and report skin issues/reddened/open areas to MD/nurse, pressure reducing device to bed and chair, provide incontinence care as needed, and skin checks to be completed with showers.

The resident’s care plan included no additional measures to prevent pressure sores, such as pressure relief for the resident’s heels or a scheduled time interval for repositioning the resident since the resident required moderate assistance from staff for rolling bed and was dependent on staff for transfers.

Review of physician orders revealed no physician ordered turning/repositioning schedule or physician ordered an off-loading intervention device to prevent heel wounds in a resident identified at-risk for pressure ulcers.

Review of a facility incident report dated January 3, 2024, at 3:30 AM revealed that a nurse aide noted an open area on Resident 23’s sacrum while providing care. Employee 7 (RN) measured the open area as 3 cm x 5 cm on the sacrum. Employee 1 indicted that the area was cleansed with saline and covered with a non-adhering dressing. The resident’s responsible party and physician were notified. No further description of the appearance of the open area was noted on the incident report.

There was no corresponding documentation in the resident’s clinical record regarding the resident’s sacral pressure sore.

Review of Employee 8 (nurse aide) witness statement dated January 3, 2024, (no time indicated) revealed that Employee 2, a nurse aide, was providing care on resident when I saw the skin tear on butt.

Review of Employee 9’s (LPN licensed practical nurse) witness statement dated January 3, 2024, (no time indicated) revealed Employee 2 called her into the resident’s room, reporting that Resident 23 had an open area on her sacrum. Employee 9 observed a 3 cm x 5 cm open area on the resident’s sacrum with scant amount of blood noted. The RN supervisor ws notified.

Review of Employee 10, LPN, witness statement dated January 3, 2024, (no time indicated) reported that she was told by nurse that Employee 2 found an open wound area on Resident 23’s sacrum. Area was known but not charted on.

Review of Employee 11, a nurse aide’s witness statement dated January 3, 2024, (no time indicated) reported aide on 11-7 shift noticed area on Resident 23’s bottom. It has been a known area but never officially documented.

During an interview with the Director of Nursing (DON) on February 8, 2024, at approximately 2:30 PM, the DON stated that she was unaware that two of the nursing staff’s witness statements reported that staff were aware of the presence of an open area on the resident’s sacrum prior completion of incident report on January 3, 2024. The DON confirmed it is the facility’s policy to report and document any skin changes in the resident’s medical record and it is the expectation that staff will report and document on any skin changes in the medical record. The DON was unable to provide any documented evidence that the facility’s follow up efforts to ascertain why nursing staff failed to timely document the identification and assessment of the resident’s pressure sore in the clinical record and obtain orders for treatment.

Review of the wound evaluation & management summary dated January 5, 2024, at 1:29 PM, revealed that the consultant wound care physician staged the resident’s sacrum as a stage 3 pressure wound full thickness (Stage 3 – a serious wound caused by pressure in which the wound has worn through all skin layers, exposing the fat. At this stage, there may be undermining and/or tunneling that makes the wound much larger than it may seem on the surface) measuring 3 cm in length by 2 cm in width by 0.2 cm in depth. It was reported that the duration of the wound was greater than 10 days old. Recommendations included: cleanse with saline at time of dressing change, off-load wound, reposition per facility policy and low air loss mattress.

Facility turning and repositioning tracking forms dated from April 2023, through December 31, 2023, revealed no documented evidence that staff turned and repositioned Resident 23 at least every two hours as noted on the resident task form. The turn and reposition task indicated that the frequency of the task was completed every shift.

Review of a facility provided documentation titled Point of Care Audit Report for Resident 23’s turn and reposition schedule dated for April 2023 through December 2023, revealed that staff failed to turn/reposition the resident timely and consistently every 2 hours as noted on the resident’s task form. Facility documentation revealed that staff turned/repositioned Resident 23  one to three times per day. The turn/reposition documentation and times the resident was turned/repositioned for December 22, 2023, through December 31, 2023, were as follows:
December 22, 2023 – 5:45 AM, 9:45 PM
December 23, 2023 – 5:45 AM, 1:45 PM, 9:45 PM
December 24, 2023 – 5:45 AM, 9:45 PM
December 25, 2023 – 9:45 PM
December 26, 2023 – 5:45 AM, 9:45 PM
December 27, 2023 – 5:45 AM, 9:45 PM
December 28, 2023 – 5:45 AM
December 29, 2023 – 5:45 AM, 9:45 PM
December 30, 2023 – 5:45 AM, 1:45 PM
December 31, 2023 – 5:45 AM, 9:45 PM

The facility failed to demonstrate timely and consistent turning and repositioning of the resident to prevent the development of a State 3 pressure sore.

Review of Resident 23’s NSG- SKIN-Pressure Ulcer Record ([NAME])- V2 dated January 4, 2024, at 11:17 AM, revealed a new wound evaluation for the resident’s right heel. The report indicated that the wound was a facility acquired Stage 1 wound, measuring 3 cm in length x 2 cm in width.

Observation of Resident 23’s wound treatment in the presence of Employee 12, RN, and consultant wound care physician on February 9, 2024, at 9:48 AM, revealed a stage 4 sacral pressure ulcer measuring 11 cm in length x 9 cm in width x .5 cm in depth with moderate serous drainage. The consultant wound care physician indicated that the wound’s deteriorating condition was exacerbated by Resident 23’s generalized decline and compromised nutritional status.

Further observation of the resident’s pressure sores on February 9, 2024, revealed an unstageable deep tissue injury of the right medial heel measuring 2 cm in length x 3 cm in width, an unstageable deep tissue injury of the right distal medial 1st toe bunion measuring 0.2 cm in length x 0.2 cm in width, an unstageable deep tissue injury of the right medial midfoot measuring 2 cm in length x 1 cm in width, and an unstageable deep tissue injury of the right ankle measuring 1 cm in length x 2 cm in width.

The facility failed to provide documented evidence that the facility developed, implemented and provided preventative measures to prevent the development of pressure ulcers and deep tissue injuries on the resident’s feet.

Interview with the Nursing Home Administrator (NHA) on February 9, 2024, at 8:30 AM confirmed that the facility was unable to documented evidence that preventative measures were timely and consistently implemented to prevent the development of a stage 3 pressure injury of the sacrum and a deep tissue injury of the right foot for Resident 23.

Personal Note from NHA – Advocates: NHAA shares with all the families of loved ones who are confined to nursing homes the pain and anguish of putting them in the care of someone else. We expect our loved ones to be treated with dignity and honor in the homes we place them. We cannot emphasize enough to family members of nursing home residents; frequent visits are essential to our loved ones’ well-being and safety. This nursing home and many others across the country are cited for abuse and neglect.

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