Tunkhannock, PA – The Gardens at Tunkhannock

Based on review of clinical records, observations ans staff and resident interviews, it was determined that the facility failed to consistently provide planned care and services, consistent with professional standards of practice, to prevent pressure sore development and promote healing of pressure sores for one out of four sampled residents (Resident 91).

A review of nursing documentation dated (MONTH) 22, 2019, at 9:31 PM revealed staff discovered an unstageable left heel ulcer after noticing blood on the resident’s bedsheet during care. The nurse aide reported the finding to the nurse, who cleansed the area with normal saline solution and wound cleanser; hydrogel was applied and the area was covered with clean dry dressing.

New interventions put into place at the time of the discovery of the pressure area on (MONTH) 22, 2019, were to apply heel bows (medical designed to offload pressure from the heel of a non-ambulatory individual to help prevent pressure ulcers) to bilateral feet, while in bed.

A physician order [REDACTED]. A new order was noted on that date to provide prevalon boots (boot heel protection device that completely offloads the heel to help prevent the development of heel pressure ulcers) while in bed, every shift.

According to interview with the Director of Nursing (DON) on (MONTH) 3, 2019, the resident was noted to kick the heel bows off and therefore an order was obtained for prevalon boots.

There was no documented evidence in the nursing progress notes or resident’s care plan regarding the resident’s known behavior of kicking off the heel bows planned to promote healing and prevent worsening of the pressure sores. The facility had assessed the resident as cognitively intact, but was unable to provide documented evidence of education provided to the resident regarding the benefit of heel bows in an effort to promote compliance with their use.

An observation of the resident’s left heel wound on (MONTH) 3, 2019 at 1:05 PM, revealed the resident lying in bed with a prevalon boot to his right foot (the foot without the pressure sore) and a heel bow and gauze at the bottom of the resident’s bed, not on the resident’s foot. The resident’s left foot, which had the unstageable pressure area was completely exposed. There was no dressing intact and no prevalon boot in place as prescribed. The resident’s bare left heel was positioned directly atop the sheet with bloody drainage approximately eight inches by 3 inches in diameter, observed on his sheet. Interview attempts at that time revealed that the resident was unable to state why his left foot was exposed, why it was not off loaded or why the protective boot was not in place. The resident was asked if the staff reposition him, elevate his feet or encourage him to reposition himself and he was unable say, but did indicate that he was in pain.

Interview with the Employee 1 (Registered Nurse), Employee 6 (Licensed Practical Nurse) and Employee 7 (Nurse Aide) on (MONTH) 3, 2019, at 1:15 PM, while observing the resident’s wound, revealed that none of the employees were able to explain why the resident left heel wound was exposed, lying on the sheet without a covering, a prevalon boot or elevation off the bed.

During an observation of the resident’s left foot wound on (MONTH) 3, 2019, at 1:15 PM, it was observed the wound covering the outer aspect of the heel, defined wound margins with slough around the outer portion of the wound and the wound was red/brown in color. The depth of the wound could not be observed, but bloody drainage was observed.

An interview with the DON on (MONTH) 4, 2019 at 12:15 PM acknowledged that the facility was unable to demonstrate the consistent implementation of measures planned to prevent pressure ulcers for this resident at risk for skin breakdown. The DON also provided no explanation why the resident was not utilizing the ordered prevalon boot to his left heel or why the wound was exposed during the surveyor’s observation on (MONTH) 3, 2019.