Other·September 8, 2023

F686 §483.25(b) Skin Integrity §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. Findings: Review of the National Pressure Injury Advisory Panel's (NPIAP) Clinical Practice Guideline titled Prevention and Treatment of Pressure Ulcers/Injuries dated 2019 defined the pressure injury stages as follows: - Stage 1: intact skin with a localized area of non-blanchable erythema (superficial reddening of the skin), which may appear differently in darkly pigmented skin. - Stage 2: partial thickness skin loss with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) tissue is not visible and deeper tissues are not visible. - Unstageable: full-thickness skin loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar (dead tissue). Review of the facility's P&P titled Pressure Injury Risk Assessment revised 3/2020 showed to develop the resident-centered care plan and interventions based on the risk factors identified in the assessments, the condition of the skin, the resident's overall clinical condition, and the resident's stated wishes and goals. Review of the facility's P&P titled Pressure Ulcers/Skin Breakdown revised 4/2018 showed the physician will order pertinent wound treatments, including pressure reduction surfaces, wound cleansing and debridement approaches, dressings (occlusive, absorptive, etc.), and application of topical agents. 1. On 8/8/23 at 0823 hours, an interview was conducted with Family Member 1. Family member 1 stated Patient 3 had two pressure injuries on his upper and lower back areas upon admission to the facility on 7/11/23. Family Member 1 stated she requested the facility to transfer Patient 3 to the acute care hospital because she was concerned Patient 3's wounds were getting "worse." Family Member 1 stated Patient 3's wounds on his back areas were increasing in size and appeared more reddened in color. Family Member 1 stated Patient 3 was in pain because of the wounds on his back. Closed medical record review for Patient 3 was initiated on 8/8/23. Patient 3 was admitted to the facility on 7/11/23, and discharged on 7/29/23. Review of the acute care hospital's medical record titled SNF Placement Request Report dated 7/10/23, showed Patient 3 had the Stage 2 pressure injuries to the sacrum and "back." The Stage 2 back pressure injury had pink wound base and partial thickness skin loss. The pressure injury did not have drainage or odor, and the surrounding skin did not have erythema. Review of the acute care hospital's medical record titled Patient Care Transfer Summary dated 7/11/23, showed Patient 3 had the Stage 2 pressure injuries to the sacrum and "upper back." Review of Patient 3's Admission/Readmission Data Tool dated 7/11/23, completed by facility staff showed Patient 3 had two partial thickness skin loss (shallow open ulcer with red, pink wound bed) areas on the back and sacrum. Patient 3's Weekly Wound Evaluation dated 7/12/23, showed Patient 3 had the right and left heels Stage 1 pressure injuries and sacro coccyx Stage 2 pressure injury. The document did not include the patient's back pressure injury. Review of Patient 3's Progress Notes showed a Skin/Wound Note entry dated 7/12/23 at 2010 hours, showed the following skin alterations: - Sacro coccyx Stage 2 pressure injury measuring 3.5 cm (length) x 3.0 cm (width) x 0.1 cm (depth) and wound bed with 100% granulation, light drainage and peri wound macerated (wet, white tissue); - BUE (bilateral upper extremity) with scattered purplish skin discoloration; - Right heel Stage 1 pressure injury, wound bed with non-blanchable redness; and - Left heel Stage 1 pressure injury, wound bed with non-blanchable redness. * However, the progress note did not include the Stage 2 pressure injury on the patient's back as shown on the facility's Admission/Readmission Data Tool dated 7/11/23. Review of Resident 3's plan of care showed the care plan problems addressing the pressure injuries to the patient's sacro coccyx and right and left heels. There was no documented evidence a care plan problem was developed to address the patient's Stage 2 back pressure injury until it had deteriorated to an unstageable pressure injury identified on 7/14/23. Further review of Patient 3's medical record showed no documented evidence of wound treatment provided to the Patient's Stage 2 back pressure injury. There was no documented evidence the patient's back pressure injury had healed. Review of Patient 3's IDT Wound Management Assessment dated 7/14/23, showed Patient 3 had the pressure injuries with the wound origin documented as admitted wound, including the unstageable "mid spine" pressure injury, measuring 14 cm x 6 cm x UTD (unable to determine) with 100% slough. Review of Patient 3's MDS dated 7/17/23, showed Patient 3 was cognitively intact and required extensive assistance from two or more staff members for bed mobility (how the Patient moved to and from a lying position, turned side to side, and positioned her body while in bed) and extensive assistance from one staff member for toilet use (including how the Patient was cleaned after elimination and pad changes). Review of Patient 3's Treatment Administration Record for July 2023 showed a physician's order dated 7/14/23 at 0859 hours, to cleanse the unstageable mid spine pressure injury with normal saline, pat dry, apply Medihoney (healing gel used to speed up the healing of burns and wounds), and cover with a foam dressing. Review of Patient 3's plan of care showed a care plan problem dated 7/14/23, addressing the unstageable mid spine pressure injury. The interventions included to provide the treatment as ordered, assess the wound weekly, reposition the Patient every two hours, assess the Patient's pain and intervene accordingly, provide skin care during ADL care, and observe/report signs and symptoms of infections. Review of Patient 3's Skin & Wound Evaluation dated 7/20/23, showed Patient 3's unstageable spine pressure injury with 50% granulation (the appearance of the red, bumpy tissue in the wound bed as the wound heals), and 50% slough, measuring 5.4 cm x 1.4 cm and depth measurement not applicable. The surrounding tissue had erythema and was macerated. Patient 3 complained of a pain level of 9 on a 0 to 10 pain scale (with o = no pain and 10 = worst pain) during treatment. Review of Patient 3's Skin & Wound Evaluation dated 7/27/23, showed Patient 3's unstageable mid spine pressure injury with 100% granulation and 50% slough, measuring 7.8 cm x 1.6 cm, and depth measurement not applicable. The assessment showed the pressure injury had evidence of infection: redness/inflammation and the wound was deteriorating. The surrounding tissue was denuded (loss of epidermis caused by exposure to urine, feces, body fluids, wound exudate, or friction), macerated and had erythema. Patient 3 complained of pain level 6 during treatment. Review of Patient 3's Physician Order dated 7/29/23, showed an order to transport the Patient to an acute care hospital for further evaluation of pressure injuries. On 8/9/23 at 1002 hours, an interview and concurrent closed medical record review was conducted with the DON. The DON acknowledged the above findings and verified Patient 3 had a Stage 2 upper back pressure injury upon admission to the facility on 7/11/23. The DON verified the Weekly Wound Evaluation on 7/12/23, did not show Patient 3's Stage 2 upper back pressure injury. The DON verified the initial wound treatment for the upper back pressure injury was started on 7/14/23, after the pressure injury was classified as an unstageable pressure injury. The DON verified Patient 3 did not have a physician's order for wound care consult and Patient 3 was not evaluated by the wound care specialist prior to discharging on 7/29/23. On 8/9/23 at 1025 hours, an interview and concurrent closed medical record review was conducted with LVN 3. LVN 3 stated the initial skin assessment was completed upon admission on 7/11/23, which showed Patient 3 having partial thickness skin loss to the back. LVN 3 stated LVN 4 completed the skin reassessment on 7/12/23. LVN 3 stated she reassessed Patient 3's wounds on 7/14/23, and observed Patient 3 with an unstageable mid spine pressure injury. LVN 3 verified she initiated the wound treatment for Patient 3's unstageable mid spine pressure injury on 7/14/23. LVN 3 stated Patient 3 was referred to a wound care specialist; however, LVN 3 verified Patient 3 did not have a physician's order for a wound care consult and Patient 3 was not evaluated by the wound specialist prior to his transfer to the acute care hospital. LVN 3 verified Patient 3's medical record did not show the facility addressed, provided wound treatment, or implemented the necessary interventions to prevent further skin breakdown of Patient 3's pressure injury on the back prior to 7/14/23. 2. Review of the Med-Aire 8", 14027 System Manual for the LAL mattress showed the system is a high-quality powered air support surface that is specifically designed for the prevention and treatment of pressure injuries while optimizing patient comfort. The manual showed effective pressure redistribution therapy, wound management and device selection should be based on the patient's specific clinical condition and complete assessment of needs. The user can adjust the pressure level of the air mattress, using the analog pressure dial, to a desired firmness based on personal comfort or weight setting. A concurrent observation and interview with Patient 1 was conducted in Patient 1's room on 8/8/23 at 0859 hours. Patient 1 was observed lying on a LAL mattress and positioned on her back. The LAL mattress was on and set between 300 and 350 pounds. Patient 1 stated the mattress was firm and she felt uncomfortable at times when positioned on her back. Medical record review for Patient 1 was initiated on 8/8/23. Patient 1 was admitted to the facility on 7/4/23. Review of Patient 1's MDS dated 7/10/23, showed Patient 1 had an unstageable pressure injury and required extensive assistance from two or more staff members for bed mobility. On 8/8/23 at 1423 hours, Patient 1 was observed lying on a LAL mattress. The LAL mattress was on and set between 300 and 350 pounds. On 8/8/23 at 1425 hours, an observation and concurrent interview was conducted with LVN 2. LVN 2 verified the LAL mattress was on and set at 325 pounds. LVN 2 stated the treatment nurses were responsible for monitoring the use and settings for the LAL mattresses. On 8/8/23 at 1443 hours, an observation and concurrent interview was conducted with LVN 1. LVN 1 was asked what the purpose of the LAL mattress was and whether Patient 1's LAL mattress was on the correct setting. LVN 1 stated the purpose of the LAL mattress was to prevent putting too much pressure on the Patient's wound causing the wound to get worse. LVN 1 verified the LAL mattress was on and set between 300 and 350 pounds. LVN 1 stated the LAL mattress should be set at 100 pounds because Patient 1 weighed 93 pounds. LVN 1 stated the LAL mattress setting should be based on the Patient's weight. On 8/8/23 at 1451 hours, an interview was conducted with the DON. The DON stated the treatment nurses and licensed nurses should be checking for the correct settings on the LAL mattress every shift. The DON stated the LAL mattress should be set at 100 pounds because Patient 1 weighed 93 pounds. This violation had a direct or immediate relationship to the health, safety, or security of the client.