Other·June 30, 2021

F684- 483.25 Quality of care. Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices, including but not limited to the following: The facility failed to provide the necessary care and services to ensure one of two sampled residents (Resident 1) attained and/or maintained their highest practicable physical well-being. The facility failed to ensure the daily wound care treatment was provided to Resident 1's right heel diabetic ulcer as ordered by the physician. In addition, the facility failed to obtain a physician's order for wound care treatment from 3/29 to 4/5/21. As a result, Resident 1 was transferred to the acute care hospital for the right heel wound infection and required surgical intervention. Findings: Review of the facility's Policy and Procedure titled Wound Care revised October 2010 showed preparation is included to verify if there is a physician's order for the procedure. Documentation should be recorded in the medical record including the name and title of the individual performing the wound care, any change in the resident's condition, all assessment data obtained when inspecting the wound, and if the resident refused the treatment and the reason(s) why. Medical record review for Resident 1 was initiated on 4/9/21. Resident 1 was readmitted to the facility on 1/16/21. Review of the MDS (Minimum Data Set, a standardized assessment tool) dated 3/29/21, showed Resident 1 had no cognitive impairment. Review of the Non-Pressure Sore Skin Problem Report dated 1/16/21, showed Resident 1 was noted with a diabetic ulcer on the right heel, which was described as dry and stable eschar (dead tissue) measuring 3 cm (centimeter) x 3 cm. Review of the Physician Orders List showed an order dated 2/28/21, to cleanse Resident 1's right heel diabetic ulcer with saline solution, pat dry, apply povidone iodine (antiseptic used to decrease the risk of infection), and wrap with a gauze everyday for 30 days. Review of Resident 1's Treatment Record for March 2021 showed the wound treatment to the right heel diabetic ulcer was scheduled daily on the 0700 to 1500 hour shift, with a stop date of 3/28/21. However, the wound care was not signed as provided on 3/6, 3/7, 3/13, 3/14, and 3/20/21. Further review of the Treatment Record failed to show the wound care was provided to Resident 1's right heel diabetic ulcer after 3/28/21. Review of Resident 1's right heel diabetic ulcer Weekly Progress Report showed the weekly wound assessments from 1/29 to 3/26/21. The wound was assessed as dry, stable eschar, measuring 3 cm x 3 cm, with no signs and symptoms of infection. On 4/2/21, the documentation showed the right heel diabetic ulcer was dry stable eschar, measuring 3 cm x 3 cm, but was noted to have foul odor and drainage. However, review of the medical record failed to show documentation Resident 1's attending physician was notified of the changes in Resident 1's right heel diabetic ulcer. Review of the Departmental Notes dated 4/5/21, showed Resident 1's right heel diabetic ulcer was noted with wound edge opening and a strong foul odor. The documentation showed the Nurse Practitioner (NP) was notified and ordered doxycycline (antibiotic) 100 mg (milligrams) by mouth twice a day for right heel wound infection. Review of the medical record failed to show a physician's order for wound care treatment was obtained nor was wound care provided to Resident 1's right heel diabetic ulcer from 3/29 to 4/5/21. Review of NP 1's progress notes dated 4/5/21, showed Licensed Vocational Nurse (LVN) 3 reported Resident 1's right heel diabetic ulcer had a foul odor and drainage. Resident 1 would be sent out to the acute care hospital for further treatment and evaluation. On 5/10/21 at 1531 hours, a telephone interview was conducted with Resident 1. Resident 1 stated the care he was receiving from the facility included wound treatment on his right heel. Resident 1 was asked what treatment was he receiving for the wound on his right heel. Resident 1 stated the nurse applied iodine on the wound on his right heel, and covered with a dressing. Resident 1 stated the nurse did not apply the iodine on the wound everyday. Resident 1 stated a few days before he was transferred to the acute care hospital, nothing was done for his right heel wound. On 5/21/21 at 1425 hours, a telephone interview was conducted with LVN 3. LVN 3 acknowledged the Treatment Record was a documentation for wound care/treatments administered to Resident 1. LVN 3 verified the above findings. LVN 3 was asked what the check marks and initials meant on the Treatment Record of Resident 1. LVN 3 stated the the check marks and the initials meant the treatment was administered to Resident 1. LVN 3 verified there was no documentation to show wound care was administered on 3/6, 3/7, 3/13, 3/14, and 3/20/21. On 6/1/21 at 1215 hours, a telephone interview was conducted with the Director of Nursing (DON). The DON verified the above findings. The DON verified a renewal order was not obtained from Resident 1's physician after the last day of the wound care treatment on 3/28/21. The DON stated an order should have been obtained because the wound was not healed. The DON verified the wound care treatment was not provided to Resident 1's right heel diabetic ulcer from 3/29 to 4/5/21. Review of the acute care hospital's ED (emergency department) Provider Notes dated 4/5/21, showed Resident 1 presented to the ED with chief complaint of pain, including right heel pain with a history of wound ulcer. Review of the acute care hospital's Orthopedic Surgery consult notes dated 4/5/21, showed on examination, Resident 1 had a large 8 x 8 cm ulceration over the plantar (sole of the foot) aspect of the right heel with active purulent (with pus) drainage with abscess (swollen area within the body tissue containing an accumulation of pus). Review of Resident 1's medical record from the acute care hospital titled Operative Note dated 4/7/21, showed Resident 1 underwent right below the knee amputation on 4/7/21, with preoperative diagnoses of right foot and ankle osteomyelitis (inflammation of a bone caused by an infection) and right foot severe abscess (collection of pus usually caused by an infection). Cross reference to F580. The above violation either jointly, separately, or in any combination, presented a direct or immediate relationship to patient health, safety, or security.