Other·October 11, 2022

F686 Treatment/ SVCS to Prevent/ Heal Pressure Ulcers 483.25(b)(1) Pressure ulcers. Based on the comprehensive assessment of a resident, the facility must ensure that- (i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and (ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. On 7/14/22 at 10:02 a.m., an unannounced visit was conducted at the facility to investigate a complaint regarding the development of a pressure ulcer (synonymous with pressure sore; injuries to the skin and underlying tissue, primarily caused by prolonged pressure on the skin) for one resident (Resident 1). Resident 1 required extensive assistance to turn and reposition in bed. Due to lack of pressure-relieving devices, repositioning, and weekly monitoring of the skin, Resident 1 developed a preventable stage 3 pressure ulcer (an ulcer that has extended through dermis [second layer of skin] into the fatty subcutaneous [below the skin] tissues) on his coccyx (tailbone). The facility failed to prevent the formation of a stage 3 pressure ulcer for Resident 1. This failure caused unnecessary physical and psychosocial pain and distress to Resident 1 and delayed his initial recovery process. Resident 1 was admitted to the facility in early March 2022 with diagnoses including malignant neoplasm (a cancer) of cecum (part of intestines), muscle weakness, Parkinson's Disease (disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), difficulty in walking, and lack of coordination. During a review of the clinical record for Resident 1, the Nursing Admission Note, dated 3/7/22 by Licensed Nurse 1 (LN 1), indicated Resident 1 did not have a pressure sore upon admission. During a review of the clinical record for Resident 1, the Care Plan for "At Risk for Altered Skin Integrity," dated 3/9/22, included interventions to monitor the resident's skin for any signs of breakdown (sore, tender, red, or broken areas), weekly skin checks, a pressure relieving device for bed and to turn and reposition the resident frequently. During a review of the clinical record for Resident 1, the MDS (Minimum Data Set, an assessment tool), dated 3/10/22, indicated Resident 1 had no memory impairment and no pressure sores. It further indicated Resident 1 required extensive assistance to turn and be repositioned in bed. During a review of the clinical record for Resident 1, the point of care history, dated 3/7/22 through 5/28/22, indicated Resident 1 was turned and repositioned 12 times during his entire stay at the facility. During a review of the clinical record for Resident 1, a nursing note, dated 4/8/22 by the Treatment Nurse (Tx. Nurse), indicated she had assessed Resident 1's skin and found a worsened condition on coccyx area measuring 1.8 cm (unit of measurement) X 1 cm X UTD (Unable to Determine). It also indicated lal (low air loss) mattress had been placed that day, a month after Resident 1 was admitted to the facility. During an interview with the Director of Nursing (DON) on 8/4/22 at 12:28 p.m., DON stated the nursing note written by Tx. Nurse on 4/8/22 that the wound had been staged incorrectly. DON also stated as per description the wound was already a stage 2 (partial thickness loss of dermis) pressure ulcer. During a review of the clinical record for Resident 1, the weekly wound notes dated 4/21/22 by the Tx. Nurse, indicated, "Coccyx reclassified as stage 3 pressure injury, measures 2.1 cm x 0.6 cm x 0.2 cm..." During an interview with the Tx. Nurse, on 7/17/22 at 10:34 a.m., she stated Resident 1 had potential for skin breakdown and the care plan was not followed for preventive measures. She also confirmed the facility failed to place Resident 1 on a low air loss mattress upon admission to prevent further skin breakdown. During an interview with DON, on 7/17/22 at 12:48 p.m., she stated Resident 1's coccyx pressure sore was avoidable (if preventive measures and interventions had been in place and followed) and the facility failed to identify interventions such as turning, positioning, and monitoring for Resident 1. She further stated the facility failed to monitor the progress of the wound as it developed. In violation of the above cited standards, the facility failed to prevent the formation of a stage 3 pressure ulcer for Resident 1. This violation had a direct or immediate relationship to the health, safety, or security of residents or residents.