PUEBLO, CO-PUEBLO CENTER

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on record review and interviews, the facility failed to ensure one (#2) out of 24 sample residents were kept free from neglect.

The facility failed to ensure Resident #2 was not neglected by staff by providing the care and services the resident required to maintain the highest practicable well-being. This is evidenced by the following statements.

Specifically, the facility failed to ensure Resident #2 received the care and services required to prevent an avoidable pressure injury from developing and worsening. On 8/6/21, the resident’s representative reported she had informed a male nurse that Resident #2’s right ear had been bleeding six weeks prior. The resident’s medical record did not reveal documentation that the resident had been assessed when the injury was reported to the nurse and all prior skin checks documented no skin injury. According to the hospital documentation on 8/3/21, Resident #2’s right ear wound was classified as a deep wound that had continuous pressure causing a pressure injury which led to a defect in his right ear with signs and symptoms of an infection.
After the resident returned from the hospital on 8/3/21, the facility failed to provide the treatment and services consistent with accepted standards of practice by failing to provide the physician ordered treatment on seven occasions.

The 6/17/21, 6/24/21, 7/1/21, 7/8/21, 7/22/21 and 7/29/21 skin check assessments documented a skin check was performed with no skin injury or wounds. The 8/3/21 nursing progress note documented the resident had sustained a wound on his right ear. The strap of the facial mask was cutting into the cartilage of the resident’s right ear. The physician was notified and indicated he would be at the facility the following day to assess the wound. He ordered that a wound consult be completed for the resident. 

The 8/3/21 change of condition assessment revealed the resident had a deep wound into the cartilage of the resident’s right ear. It had a three plus cap refill (a measure of the time it takes for a distal capillary bed to regain color after pressure has been applied to cause blanching), was not bleeding, but was oozing scant serous fluid (signs of infection). The recommendation included for the resident to be evaluated at the hospital. The unit manager assessed the wound and determined the wound needed to be stitched and the resident should be sent to the hospital. The physician and power of attorney (POA) were notified and the resident was transported to the hospital.
The 8/5/21 nursing progress note documented that the resident’s representative had come to the facility that morning. She had several concerns regarding the wound to the resident’s right ear. She said she was not informed the resident had been sent to the emergency room for the wound to be evaluated. She said a month and a half ago, she had noticed the resident’s ear was bleeding and told the male nurse. She entered the resident’s room and found multiple facial masks with ear loops. The nurse apologized, removed the facial masks and provided the resident with a face shield. The nurse said she would notify the NHA of the resident’s representative concerns.
-The facility failed to identify the wound caused by the facial mask and consistently documented no skin concerns on the weekly skin assessments, put a treatment in place prior to the wound worsening from the mask digging into the resident’s ear, into the cartilage and resulting in oozing serous fluid. The facility failed to assess and document the wound to the resident’s right ear when it was reported by the resident representative six weeks prior to the documentation of 8/3/21.

D. Hospital documentation
The 8/3/21 emergency room physician notes documented Resident #2 was sent to the emergency
department because of a sore to the resident’s right ear…

It documented, When looking at the patient’s wound and discussing with the patient his care at the facility seems to be a case of neglect. I had asked the paramedic to call the facility inquiring about his ear. She states that she called the facility and spoke with the nurse at the facility who states that he was sent to the emergency department today because the patient’s sister was visiting and noticed there was something wrong with his ear. 

The DON said the former NHA was the lead on the investigation. She said she opened up the investigation, during the survey process, and it only included the documentation submitted through the state portal. She said she was unable to find documentation of the rest of the investigation. She said it appeared as though the former NHA did not try and determine who the male staff member was or complete staff interviews.

She said the documentation from the hospital indicated the wound had been present for a while and had sustained constant pressure. She said the wound should have been documented on the skin checks prior to 8/3/21. She said she would be providing the nursing staff education on how to complete a skin check and ensure the nurses were looking at all the skin surfaces of the resident. She said because she was not there at the time, she did not know if the skin checks were completed correctly, but it appeared as though they were not accurate.