In The News:
Based on clinical record reviews, staff interviews, and facility policy, the facility failed to ensure pressure ulcer interventions were provided for one resident (#2) resulting in a worsening pressure injury. The deficient practice could result in residents not receiving care and interventions to promote wound healing.
Findings include:
Resident #2 was admitted on [DATE] with diagnoses that included dependence on renal dialysis, acute kidney failure, type 2 diabetes mellitus, obesity, muscle weakness, and need for assistance with personal care.
A care plan initiated on September 17, 2020 for potential for skin breakdown included a goal that the resident would be free from injury. The interventions included to float heels and use a low air loss support service. Another care plan initiated on September 17, 2020 for actual impairment to sacrum included a goal that the resident’s wound show signs of healing and remain free from infection. The interventions for these goals included to float heels, assistance to turn and reposition, and use pressure relieving/reducing devices.
A Skin Pressure Ulcer assessment dated [DATE] at 6:39 pm included an initial evaluation for an unstageable sacral pressure injury. The assessment included that the wound measured 9.3 cm in length by 7.2 cm wide and a depth of UTD (unable to determine). The assessment included that the wound had a small amount of serosanguineous exudate. The assessment included that staff would assist with turning and repositioning.
Review of the Documentation Survey Report for September 17 through September 30, 2020 revealed no documentation for pressure reducing devices for the following dates and times:
-9:29 pm on September 18 through 3:47 pm on September 19, 2020
-9:07 pm on September 19 through 11:02 am on September 20, 2020
-7:27 pm on September 21 through 12:22 pm on September 22, 2020
-12:22 pm on September 22 through 12:12 am on September 23, 2020
-8:12 pm on September 24 through 5:59 pm on September 25, 2020
-10:27 am on September 27 through 1:06 am on September 28, 2020
-8:59 pm on September 29 through 5:14 pm on September 30, 2020
Another Skin Pressure Ulcer assessment dated [DATE] at 12:02 pm included that the sacral wound was now a stage 4 pressure injury that measured 10.3 cm in length by 3.7 cm in width with a depth of 4.6 cm. The assessment included that the wound had 4.6 cm undermining. The assessment included that the wound had a moderate amount of serosanguineous drainage. The assessment included that the wound bed had granulation tissue and the wound edges were macerated.
Review of the Documentation Survey Report for October 2020 revealed no documentation for pressure reducing devices for the following dates and times:
-1:43 am on October 1 through 5:59 pm October 2, 2020
-8:00 pm on October 3 through 3:22 pm October 4, 2020
-7:36 pm on October 8 through 3:13 pm October 9, 2020
-9:20 pm on October 12 through 12:00 pm October 13, 2020
-7:53 am on October 18 through 12:39 am October 19, 2020
-6:55 am on October 20 through 12:43 am October 21, 2020
-9:01 pm on October 22 through 7:46 am October 23, 2020
-9:09 pm on October 23 through 7:27 am October 24, 2020
-7:27 am October 24 through 12:58 am October 25, 2020
-6:47 am October 25 through 1:17 am October 26, 2020
-1:17 am October 26 through 4:59 pm October 26, 2020
-8:18 am October 27 through 3:37 am October 28, 2020
-10:27 am October 29 through 1:21 am October 30, 2020 -8:24 am October 31 through 5:53 am November 1, 2020
A Skin Pressure Ulcer assessment dated [DATE] at 11:32 am included that the sacral wound was a stage 4 pressure injury that measured 10.3 cm in length by 3 cm in width with a depth of 4.5 cm. The assessment now included that the wound had 7.5 cm undermining.
Review of the Documentation Survey Report for November 1 through 11, 2020 revealed no documentation for pressure reducing devices for the following dates and times:
-11:43 pm November 1 through 3:45 pm November 2, 2020
-7:36 am November 3 through 1:58 am November 4, 2020
-9:08 pm November 5 through 7:30 am November 6, 2020
-7:30 am November 6 through 11:03 pm November 6, 2020
-7:04 am November 7 through 12:19 am November 8, 2020
-7:56 am November 9 through 9:53 pm November 9, 2020
-6:36 am November 10 through 11:21 pm November 10, 2020
A Discharge MDS dated [DATE] included that the resident had a stage 4 pressure injury.
A facility policy titled Care and Treatment Wound Management included that it is the policy of this facility that a resident who enters the facility without pressure ulcers does not develop pressure ulcers unless the individual’s clinical condition or other factors demonstrate that a developed pressure ulcer was unavoidable. A resident having pressure ulcers receives necessary treatment and services to promote healing, prevent, infection, and prevent new, avoidable sores from developing.
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