RICHMOND, VA- ROSEDALE HEALTH & REHABILITATION

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

Based on resident interview, staff interview, facility document review and clinical record review, the facility staff failed to provide care and services to prevent and treat pressure injuries for three of 40 residents in the survey sample, Residents #106, #108 and #96. For Resident #106, the facility staff failed to assess the resident for risk for pressure injuries, failed to document pressure injuries, failed to obtain physician’s orders for the treatment of the pressure injuries, and failed to implement interventions to prevent further pressure injuries, which constituted harm.

A hospital discharge summary dated 5/18/23 failed to reveal any documentation regarding pressure injuries. R106 was admitted to the facility on [DATE]. No assessment for risk for pressure injuries was completed on the date of admission. R106’s admission screener (assessment) dated 5/18/23 documented the resident had no skin issues. The baseline care plan triggers section of the screener revealed no focus, goals, or interventions related to R106’s skin integrity.

1. For Resident #106 (R106), upon admission on 5/18/23, the facility staff failed to assess the resident for risk for pressure injuries, failed to document pressure injuries on the sacrum, left hip, right heel and left heel, failed to obtain physician’s orders for treatments for those pressure injuries, and failed to implement interventions to prevent further pressure injuries. On 6/8/23, the wound care physician identified more unstageable (1) pressure injuries on the right great toe and left great toe.

A review of nurse practitioner and physician notes from 5/19/23 through 5/24/23 failed to reveal any documentation regarding pressure injuries. The notes dated 5/19/23, 5/22/23, 5/23/23 and 5/24/23 documented, SKIN: No rash, ulcer or cyanosis. Warm and dry. No induration, nodules, or discoloration.

The facility staff failed to assess the resident’s risk for pressure injuries (until 5/23/23 when the resident was assessed as being at moderate risk for pressure injuries), failed to develop a care plan for pressure injuries (until 6/27/23), and failed to obtain physician’s orders to implement interventions to prevent and treat pressure injuries (until 6/8/23). On 6/8/23, the wound care physician evaluated R106 and ordered treatments for six different pressure injuries. These pressure injuries included the four pressure injuries documented in RN #4’s 6/7/23 skin note; an unstageable pressure injury on the sacrum, an unstageable pressure injury on the left hip, an unstageable pressure injury on the right heel and a deep tissue injury on the left heel, and two
new pressure injuries which were an unstageable pressure injury on the right great toe and an unstageable pressure injury on the left great toe.

For Resident #108 (R108), the facility staff failed to complete thorough assessments of the resident’s stage four pressure injury (1) in August 2023 and September 2023, failed to assess R108 for self-care of the pressure injury, and failed to provide oversight to ensure treatments were being completed for the pressure injury in August 2023 and September 2023.

On 9/20/23 at 1:10 p.m., an interview was conducted with R108. R108 stated he has had a wound on his buttock for over three years. R108 stated the nurses only look at the wound when he asks, and the nurses have not measured the wound, In a while. R108 stated he completes treatment for the wound twice a day and the treatment consists of soaking gauze in saline, putting the gauze in the wound, applying an adhesive bandage then covering that with another adhesive bandage.

Further review of R108’s clinical record failed to reveal the resident was assessed for self-care of the pressure injury to ensure the resident was capable of caring for the pressure injury, and failed to reveal oversight was provided to ensure the resident was providing care for the pressure injury per the physician’s order. A physician’s order dated 6/28/23 documented to cleanse the wound to the right buttock with normal saline, apply normal saline soaked gauze to the open area, and cover with a dry adhesive dressing every shift for wound care. A review of R108’s August 2023 and September 2023 TARs (treatment  administration records) revealed the same physician’s order but failed to reveal documentation that the treatments were completed each day for both months. The spaces for nurses to sign off the completion of the treatments were blank. Review of nurses’ notes for August 2023 and September 2023 failed to reveal documentation that treatments for R108’s pressure injury were completed. The only documentation of refusal of care in August 2023 and September 2023 was a nurse’s note dated 8/3/23 that documented R108 declined to be seen by the wound care physician and a nurse’s note dated 8/26/23 that documented R108 refused wound
treatment with the wound physician.

On 9/21/23 at 9:16 a.m., another interview was conducted with LPN #3. LPN #3 stated an evaluation should be completed to make sure a resident is safe and able to perform his own pressure injury care. LPN #3 stated nurses should make sure the resident has the supplies he needs for wound care, make sure the doctor is aware the resident performs his wound care, and nurses should offer assistance if needed. LPN #3 stated this should be done each time the wound care is due per the physician’s order. LPN #3 stated she had not personally assessed R108’s pressure injury on the buttock since June or July 2023 but she observed R108 perform wound care on the previous Monday. LPN #3 stated she observed the resident lay on his side and spread out and clean and pack the wound. LPN #3 stated she thought R108 was using a wet to dry
dressing and a border gauze for his pressure injury treatment. LPN #3 stated she did not document this observation and needed to complete a late entry.

3. For Resident #96 (R96), the facility staff failed to complete thorough assessments of the resident’s stage three pressure injury (1) in August 2023 and September 2023, and failed to provide treatments per physician’s orders on multiple dates in September 2023.

R96 was admitted to the facility on [DATE] with a diagnosis of a stage three pressure injury of the sacral region (1). An admission evaluation dated 8/24/23 documented an open pressure area on the sacrum. A weekly skin observation note dated 8/25/23 documented R96 was admitted with an open area to the sacrum measuring 1.5 cm (centimeters) (length) by 1.5 cm (width). A weekly skin observation dated 9/4/23 documented, Resident was admitted with an open area to sacrum (1.5cm x 1.5cm). A weekly skin observation dated 9/11/23 documented, Open area and Cleanse sacral wound with wound cleanser. Apply calcium alginate (used to treat wounds) to wound bed cover with foam dressing. A weekly skin observation dated 9/19/23 documented, admitted with open area to sacrum. The weekly skin observations failed to document a description of the pressure injury (including stage, measurements [8/24/23, 9/11/23 and 9/19/23], presence or absence of any tunneling or undermining, type of tissue, or presence or absence and type of drainage).

Further review of R96’s clinical record revealed the following physician’s orders:
8/24/23- clean the sacral area with normal saline and cover with form board gauze daily (discontinued 9/8/23).

9/8/23- cleanse the sacral wound with wound cleanser. Apply calcium alginate to wound bed and cover with foam dressing every day shift.

A review of R96’s September 2023 TARs (treatment administration records) revealed the same physician’s orders but failed to reveal documentation that the treatments were completed on 9/1/23, 9/4/23, 9/8/23, 9/10/23, 9/11/23, 9/14/23 and 9/15/23. The spaces for nurses to sign off the treatments had been done were blank. A review of nurse’s notes for all dates also failed to reveal documentation that the treatments were completed.

On 9/20/23 at 9:37 a.m., an interview was conducted with LPN (licensed practical nurse) #3. LPN #3 stated that after residents are admitted , weekly skin observations should be conducted on all residents and nurses are required to look at every resident’s skin. LPN #3 stated assessments of pressure injuries should include a description of the wound, the measurement of the size, any odor, the color, the presence of drainage, and the stage if the nurse is a RN (registered nurse). In regard to evidencing the completion of treatments, LPN #3 stated the nurses evidence treatments are done by signing the treatments off on the electronic treatment administration record.