Health inspection·October 27, 2022

§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. The facility failed to ensure the necessary care and services were provided to prevent the development and worsening of a pressure ulcer for three of three sampled residents (Residents 1, 2, and 3) and eight nonsampled residents (Residents LL, MM, NN, OO, PP, QQ, RR, and SS). * Resident 1 was incontinent and was admitted to the facility on 8/11/22, without a pressure ulcer. Resident 1 developed an unstageable pressure ulcer at the sacrococcyx (tailbone) area on 8/19/22, that had progressed to a Stage 4 on 9/7/22 (19 days after). The facility failed to provide the appropriate and necessary services to ensure Resident 1 did not develop a pressure ulcer in the facility and failed to ensure the pressure ulcer did not deteriorate. This failure resulted in Resident 1's cancellation of discharge to home and receiving intravenous antibiotics for a wound infection. * Resident 3 had a reopened Stage 2 pressure ulcer on the right buttock. The licensed nurse failed to assess the pressure ulcer, notify the physician resident's representative, and obtain a treatment order for the pressure ulcer. This failure resulted in the CNA providing inappropriate wound treatment and the potential for Resident 3 not receiving appropriate care and services to promote healing of the pressure ulcer. * The facility failed to follow and implement the physician's orders to provide the wound treatments to Residents 2, 3, LL, MM, NN, OO, PP, QQ, RR, and SS's for their pressure ulcers on 8/27, 8/28, and 8/30/22, when the facility did not have an assigned treatment nurse to perform their wound treatments. This failure posed the risk for delayed healing and worsening of the pressure ulcers. Findings: Review of the facility's P&P titled Skin and Wound Management revised 1/1/12, showed the facility staff will take appropriate measures to prevent and reduce the likelihood that the residents will develop pressure ulcers and other skin conditions. All nursing staff is responsible for the prompt reporting of any skin related conditions to the licensed nurse. The licensed nurse will notify the Attending Physician promptly at the first occurrence of a pressure ulcer or other skin related problems. Review of the facility's P&P titled Pressure Ulcer Management revised 1/1/12, showed at any time when a new pressure ulcer is identified, the licensed nurse will complete the Pressure Ulcer Site Sheet. The Attending Physician will be notified to obtain advise/orders on the appropriate treatment promptly. The Licensed Nurse will notify the responsible party of the presence of the pressure ulcer. The National Pressure Ulcer Advisory Panel released definitions of pressure ulcers on April 13, 2016, as follows: - Stage 1 pressure ulcer - intact skin with a localized area of non-blanchable erythema (redness). - Stage 2 pressure ulcer - partial thickness skin loss of dermis presenting as a shallow open ulcer with a red, pink wound bed, without slough (dead tissue). May also present as an intact or open/ruptured serum-filled blister. - Stage 3 pressure ulcer - full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon, or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling (damage to tissue beneath the skin surrounding the pressure ulcer). - Stage 4 pressure ulcer - full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar (dead tissue) may be present on some parts of the wound bed. Often includes undermining and tunneling. - Unstageable pressure ulcer - full thickness tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. - Deep Tissue Pressure ulcer - Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or epidermal separation revealing a dark wound bed or blood-filled blister. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. 1. Medical record review for Resident 1 was initiated on 8/31/22. Resident 1 was admitted to the facility on 8/11/22. On 8/31/22 at 0942 hours, Resident 1 was observed lying flat on a low air loss mattress (mattress used for prevention or treatment of skin breakdown). Review of Resident 1's MDS dated 8/18/22, showed Resident 1 did not have a cognitive impairment. Resident 1 required total assistance of one staff for toileting (including how the resident was cleaned after elimination and pad changes), personal hygiene, and bed mobility (how the resident moved to and from a lying position, turned side to side, and positioned her body while in bed). Resident 1 was always incontinent of bowel and bladder. Review of the Clinical Admission Evaluation dated 8/11/22, showed Resident 1 was admitted to the facility without a pressure ulcer. Review of the Skin Only Evaluation dated 8/12/22, showed Resident 1 had a Moisture Associated Skin Damage (MASD, inflammation and erosion of the skin caused by prolonged exposure to various sources of moisture) to the sacrococcyx extending to bilateral buttocks. The length and width measurement showed diffuse (spread out). a. Review of the Treatment Administration Record for August 2022 showed a physician's order dated 8/13/22, to cleanse the sacrococcyx extending to bilateral buttocks MASD with warm, soapy water, pat dry, and apply a skin barrier daily every shift. However, the treatment was not done on 8/13/22, for the night shift and from 8/15 to 8/17/22, for the evening shifts. Review of the plan of care showed a care plan problem dated 8/18/22, addressing Resident 1's risk for further skin impairment. The interventions included to assist and encourage the resident to reposition every two hours and as needed with a pillow or assistive devices for skin maintenance and integrity. Review of the CNAs ADL Flow Sheet for August 2022 showed Resident 1 was dependent with one staff member for bed mobility. However, there was no documentation to show the frequencies of Resident 1 being turned and repositioned on each shift. Review of the Change in Condition Evaluation dated 8/18/22, showed Resident 1 had a new onset unstageable pressure ulcer/injury to the sacrococcyx extending to right upper buttock, measuring 5.8 cm (length) x 3 cm (width) x UTD (unable to determine, full thickness tissue loss in which the base of the ulcer was covered by slough [excessive pus] and/or eschar [dead tissue]). The wound was described as 50% slough adherent to the wound bed and 50% granulating pinkish/red fragile tissue. On 8/31/22 at 1145 hours, an interview and concurrent medical record review was conducted with LVN 3. LVN 3 verified the above findings. LVN 3 verified Resident 1 was admitted to the facility with MASD to the sacrococcyx extending to bilateral buttocks and treatment was not consistently done as per the physician's order. LVN 3 was asked how an MASD had deteriorated to an unstageable pressure ulcer without someone noticing when it was Stage 1 or 2 and so forth. LVN 3 stated she had no answer. LVN 3 stated the skin breakdown should have been found when it was at least a Stage 2 as the pressure ulcer would not become unstageable right away, considering the size of the pressure ulcer when it was discovered. On 8/31/22 at 1205 hours, an interview was conducted with Resident 1. Resident was observed lying flat on a low air loss mattress. Resident 1 stated she had a wound at "...the bottom." When asked if the staff were turning or repositioning her every two hours, Resident 1 stated "...not as much." Resident 1 stated the nursing staff were always busy. When asked if she could turn and reposition in bed by herself, Resident 1 stated no, she needed help. On 8/31/22 at 1215 hours, an interview was conducted with CNA 2. CNA 2 stated she was familiar with Resident 2. Resident 2 needed total assistance from one staff with turning and repositioning. When asked where they documented the turning and repositioning of the resident, CNA 2 stated they did not document these. CNA 2 stated they did not have a turning schedule to follow. On 9/13/22 at 0511, 0645, and 0835 hours, Resident 1 was observed lying flat on a LAL mattress. On 9/13/22 at 0629 hours, an interview was conducted with CNA 5. When asked where the staff would document the turning and repositioning of the resident, CNA 5 stated they did not document turning and repositioning in the ADL flowsheets. CNA 5 stated the facility did not have a turning schedule, but she followed the 12, 2, 4, and 6 schedule (the time on the clock she repositioned the resident). On 9/13/22 at 0641 hours, an interview was conducted with LVN 6. LVN 6 stated the facility did not have a turning schedule. LVN 6 stated he followed the 11, 1, 3, 5, and 7 turning schedule (the time on the clock the resident was repositioned). On 9/1/22 at 0720 hours, an interview was conducted with CNA 1. CNA 1 stated the facility was always short-staffed during the night shift. CNA 1 stated there were times only three CNAs were assigned to provide care to 96 to 100 residents. CNA 1 stated when they were short staffed, the CNAs could only answer call lights and only change the incontinent residents only once. CNA 1 stated they did not have time to turn and reposition the residents. Cross reference to F725, example #1. b. Review of the Wound Assessment and Plan Assessment dated 8/30/22, showed Resident 1 was evaluated by the Wound Consultant for the first time on 8/30/22. The assessment showed Resident 1 had an unstageable pressure injury (same as ulcer) on the sacrum measuring 8.2 cm x 4.8 cm x 0.4 cm. The documentation showed a treatment order to apply Santyl (removes dead tissue from wounds so they can start to heal), nickel thick layer; cleanse the wound with normal saline or sterile water before applying the dressing; and cover with moist gauze daily and as needed. Review of the Skin Only Evaluation dated 8/30/22, showed Resident 1 was seen and evaluated by the Wound Consultant and a bedside sharp debridement was performed. The documentation showed Santyl ointment with moist gauze was the current treatment order. Review of the Order Summary Report showed an order dated 8/31/22, to cleanse the sacroccoccyx extending to right upper buttock pressure injury with normal saline, pat dry, apply Santyl ointment and cover with a dry dressing everyday shift. The wound care treatment order was transcribed incorrectly as per the Wound Consultant's treatment order to cover the wound with moist dressing after applying Santyl ointment instead of the dry dressing. On 9/13/22 at 0910 hours, a wound care observation on Resident 1 was conducted with LVN 2. LVN 2 was observed cleansing Resident 1's sacrococcyx wound with normal saline, applied Santyl ointment, and covered the area with a dry dressing. On 9/19/22 at 1129 hours, a telephone interview and concurrent medical record review was conducted with RN 2. RN 2 verified the above treatment order was transcribed incorrectly. The Wound Consultant's order was to cover the wound with moist dressing. RN 2 stated he would clarify the order with the physician. c. Review of the physician's order dated 8/24/22, showed an order from Resident 1's primary care physician to change the pressure ulcer's dressing two times a day. Review of the Treatment Administration Record for August 2022 showed a physician's order dated 8/24/22, to cleanse the sacrococcyx extending to the right buttock pressure injury with normal saline, pat dry, apply Santyl ointment, and cover with a dry dressing two times a day-on-day shift (0700 to 1500 hours) and evening shift (1500 to 2300 hours). However, the treatment order was not done on the evening shift from 8/24 to 8/30/22. On 8/31/22 at 1222 hours, an interview and concurrent medical record review was conducted with LVN 4. LVN 4 verified the wound treatment was not done in the evening shift from 8/24 to 8/30/22, as ordered by the physician. d. Review of Resident 1's physician's orders showed the following orders dated: - 8/23/22, LCD (last cover day, last day of Medicare coverage) 9/5, d/c (discharge) 9/6 with home health. - 8/31/22, cancel LCD due to a wound. e. Review of the Physician's Telephone Orders dated 9/7/22, showed an order for vancomycin (antibiotic used for life-threatening bacterial infections) intravenous (injected into the vein) injection for seven days due to a Stage 4 wound infection. Review of Resident 1's primary care physician's Progress Note dated 9/7/22, showed Resident 1's wound was now a Stage 4 with visible bone. A wound culture was ordered. Review of the Sacrococcyx Wound Culture result dated 9/7/22, showed the sacrococcyx wound was positive for pseudomonas aeruginosa (bacteria capable of causing a variety of infections) and enterococcus faecalis (bacteria inhabiting the gastrointestinal tracts of humans associated with nosocomial infections). On 9/19/22 at 1335 hours, a telephone interview and concurrent medical record review was conducted with LVN 2. LVN 2 stated she worked as a treatment nurse at the facility. LVN 2 stated she was the one who found out about the unstageable pressure ulcer of Resident 1 on 8/18/22. LVN 2 stated she was just reassigned from another area and the CNA asked her to put "... a bandage" on Resident 1. LVN 2 stated when she checked the physician's order, she only saw an order for a barrier cream, so she questioned the CNA. LVN 2 stated the CNA said Resident 1 had a bandage on her bottom. LVN 2 stated when she checked, Resident 1 had an unstageable pressure ulcer at the sacrococcyx extending to the right buttock. LVN 2 stated she could not explain why it was not assessed or evaluated before the pressure ulcer became unstageable. On 9/20/22 at 1357 hours, a telephone interview was conducted with Resident 1's family member. The family member stated the plan was for Resident 1 to be discharged home on 9/5/22; however, because Resident 1 developed a pressure ulcer in the facility, her discharge schedule had been canceled. The family member stated Resident 1 did not have a pressure ulcer when she was admitted to the facility from the acute care hospital. The family member stated they were very involved in Resident 1's care and would visit her often. When asked if the facility staff turned and repositioned Resident 1 every two hours, the family member stated no. The family member stated sometimes Resident 1 was not repositioned or changed for three to six hours. On 9/21/22 at 1035 hours, an interview was conducted with Resident 1's primary care physician. The physician stated Resident 1 developed an unstageable pressure ulcer at the facility for that reason the resident's planned discharge date had been canceled. Resident 1's primary care physician stated she saw Resident 1's wound on 9/7/22, after the treatment nurse reported there was a foul odor coming from the wound and the wound was covered with slough, so she ordered the intravenous vancomycin injection. The physician stated the wound culture came back positive with bacterial infection. 2.a. On 9/13/22 at 0515 hours, an observation of CNA 1 providing incontinence care to Resident 3 was conducted. CNA 1 was observed applying miconazole nitrate (antifungal cream used to treat athlete's foot, jock itch or ringworm) 2% to Resident 3's buttocks. Resident 3 was observed with an open wound measuring approximately 1.5 cm x 1.5 cm at the right buttock. Medical record review for Resident 3 was initiated on 9/13/22. Resident 3 was admitted to the fa