PUEBLO, CO- PUEBLO CENTER

Based on observations, record review and interviews, the facility failed to provide the necessary treatment and services to prevent pressure injuries from occurring and worsening for three (#12, #6, and #2) of five out of 24 sample residents.

Specifically, the facility failed to ensure Resident #12’s pressure injury to the coccyx/sacrum did not worsen. Resident #12, who was at high risk for developing pressure injuries, was admitted to the facility with a healing stage 2 pressure injury to the sacrum/coccyx. The facility failed to encourage the resident to reposition and follow physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] .

The facility failed to ensure treatments were provided as ordered by the physician and develop a
person-centered care plan for the resident’s pressure injury to the sacrum/coccyx.

Resident #12 was admitted to the facility with a stage 2 pressure injury to her sacrum. The facility’s failure contributed to the worsening of Resident #12’s pressure injury worsening from a healing stage 2 to her sacrum/coccyx to an unstageable wound on 3/23/22. The resident was sent to the hospital on 4/20/22 due the fever and possible sacral wound infection. When the resident return from the hospital on 4/25/22, the sacral/coccyx wound was debrided and classified as a stage 4.
Additionally, the facility failed to:
-Ensure treatments were provided as ordered by the physician for Resident #6’s pressure injury to the sacrum; and,
-Ensure Resident #2 was repositioned timely.

Resident #12 was interviewed on 5/25/22 at 6:25 p.m. The resident said that she did have a pressure ulcer injury on her coccyx. She said she had recently returned from the hospital. She said that she was unable to move on her own and that a hoyer mechanical lift was utilized to move her from the chair to the bed. She said that she stayed in her chair for the day, and that she was not always offered to go to lie down. She said she liked to go out to smoke. She said the pressure ulcer injury would hurt at times when she had been sitting on the wound for too long.

On 5/26/22, during a continuous observation which started at 9:41 a.m. and ended at 12:30 p.m., Resident #12 was not offered or encouraged to lie down after smoking and after 30 minutes of sitting up in the wheelchair.

The 5/2/22 PCP progress note documented that the wound physician had concerns about the stage 4 pressure injury on the sacrum. It did not include the measurements of the wound. The wound had an odor. The physician had told the resident to turn every two hours, however, the resident said that staff did not offer it.

The April 2022 and the May 2022 behavior log did not show that the resident had any behaviors and refusals.

Licensed practical nurse (LPN) #1 was interviewed on 5/26/22 at 12:15 p.m. The LPN said Resident #12 had an unstageable pressure injury on her coccyx/sacrum which had worsened. He said she had returned recently from the hospital as she had an infection in the wound. She returned with a wound vacuum. He said that the wound physician followed the resident. He said the dressing was changed every 72 hours, however, he did not change the dressing. He said he assessed the dressing to ensure there were no leaks from the wound vacuum. He said the assistant director of nurses, the wound nurse or the wound physician was responsible to change the dressing every 72 hours or as needed.

The wound physician was interviewed on 5/26/22 at 2:15 p.m. The wound physician said he had been following the resident for the pressure injury since 4/2/22. He said the wound was unstageable because the depth of the pressure injury could not be seen. He said that the wound was debrided as 80% of the wound was necrotic and 20% slough. He said on 4/19/22 it started to smell and she went to the hospital. The hospital debrided it and it was now a stage 4. He said when she came back from the hospital the wound was debrided again.