PRESCOTT, AZ- GRANITE CREEK HEALTH & REHABILITATION CENTER

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 43863

Based on clinical record review, staff interviews, and policy and procedure, the facility failed to ensure consistent treatments were provided to two residents (#13, #233) with pressure ulcers.

The skin pressure ulcer weekly assessment dated [DATE] revealed a deep tissue injury (DTI) on the right heel and a stage 4 sacral pressure ulcer.

The physician order summary revealed the following active orders:
-Weekly skin assessment every day shift every Saturday;
-Clean the sacrococcygeal wound with Puracyn, pat dry, cover with dry dressing every shift;
-Treat the right heel with skin prep, twice daily every shift for wound care for 30 days;
-Clean the sacrum with Dakin’s, apply medical honey, cover with calcium alginate and foam dressing, every day shift for 30 days (order date: December 27, 2022).

Review of December 2022 Treatment Administration Record (TAR) revealed the treatment was marked as not administered on the following dates
-December 29 and 30 for the sacral wound;
-December 28 and 29 for the right heel; and,
-Sacrococcygeal ulcer on nine occasions in December 2022.

The clinical record revealed no evidence that these treatments was provided as ordered on dates marked in the TAR.

The progress notes for December 2022 revealed no evidence the physician was notified that treatment were not provided as ordered; and, no documentation of reason why treatment was not completed as ordered.

An interview was conducted on January 11, 2023 at 12:09 p.m. with a wound care nurse (RN/staff #147) who stated that the December 2022 TAR for resident #13 revealed no evidence wound care treatments were completed as ordered for the sacral and right heel wounds on multiple occasions. She also stated that the progress notes also revealed no evidence the physician had been contacted on those days, or the reason the dressings were not completed as ordered. She stated that this did not meet her expectations.

-Regarding Resident #233

A care plan initiated on October 12, 2022 revealed resident had actual stage 2 pressure ulcer of left ankle. Interventions included to administer medications as ordered and monitor for effectiveness.

Review of physician order recap revealed the following orders:
-10/17/22: Right knee: medihoney every day shift;
-10/17/22: Left Ankle: cleanse with normal saline and apply medihoney every day shift;
-10/25/22: Left Ankle: cleanse with normal saline, apply calcium alginate every day shift for pressure injury order;
-10/27/22: Left ankle: cleanse with normal saline and apply collagen powder every day shift; and,
-11/4/2022: Left ankle: cleanse with normal saline and apply collagen powder

These orders were transcribed onto the October 2022 TAR and revealed treatment was not marked as administered on multiple times for the left ankle wound and once for the right knee.

Review of the November 2022 TAR revealed no evidence that the left ankle wound dressing had been completed as ordered on November 8, 2022.

An interview was conducted on January 11, 2023 at 12:09 p.m. with a wound care nurse (RN/staff #147) who stated the risk of not completing wound treatments/dressings as ordered could result in the wound declining or an infection. She reviewed the clinical record for resident #233 and stated there was no evidence the left ankle wounds were completed as ordered four times in October 2022, and the right knee dressings once in October 2022. She also stated there was no evidence in the progress notes as to why the dressings were not completed as ordered, or of physician notification.