Health inspection·June 19, 2023

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide care and services to promote healing of pressure ulcers for 2 of 4 residents reviewed for pressure ulcers of a total sample of 13 residents, (#1 and #5). Residents Affected - Few Findings: 1. Review of resident #1's medical record revealed he was readmitted to the facility on [DATE] with diagnoses including osteomyelitis of the left ankle and foot, Methicillin Resistant Staphylococcus Aureus (MRSA), type 2 diabetes, and stroke. MRSA is an infection caused by a type of staph bacteria that becomes resistant to many of the antibiotics used to treat ordinary staph infections. (Retrieved from www.mayoclinic.org on 6/30/23). Review of resident #1's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. The assessment showed resident #1 had a Stage 3 pressure ulcer. A stage 3 pressure injury is a full-thickness loss of skin, in which adipose (fat) is visible in the ulcer. Slough and/or eschar may be visible. (Retrieved on 6/30/23 from www.npuap.org). Review of resident #1's medical record revealed a care plan for actual skin breakdown related to a Stage 3 pressure ulcer on the left ankle initiated on 3/21/23. Interventions included performing Wound care as ordered, see current treatment record and physician's orders; monitor effectiveness of / response to treatment as ordered. Review of resident #1's physician orders revealed the following wound care orders: *From 3/28/23 to 4/11/23 Left ankle - Cleanse site with NS (normal saline), pat dry apply collagen powder to wound bed followed by honey fiber and cover with border foam dressing. Every day shift. *From 4/12/23 to 4/24/23 Left ankle - Cleanse with NS, pat dry apply Medi honey to wound bed followed by collagen powder and calcium alginate then cover with border foam dressing daily every day shift. *From 4/25/23 to 5/23/23 Left ankle - Cleanse with NS, pat dry apply Medi honey to wound bed followed calcium alginate then cover with border foam dressing daily every day shift. Review of a SBAR (Situation-Background-Assessment-Recommendation) Communication Form dated 5/16/23 Page 1 of 3 105464 105464 06/19/2023 Anchor Care & Rehabilitation Center 1515 Port Malabar Blvd NE Palm Bay, FL 32905

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few revealed resident #1 had a change in condition related to ESBL (Extended-spectrum beta-lactamases) infection to the left ankle wound. Review of a Hospital Transfer Form revealed resident #1 was transferred to an acute hospital on 5/16/23. ESBLs are enzymes or chemicals produced by germs like certain bacteria. These enzymes make bacterial infections harder to treat with antibiotics. (Retrieved from www.webmd.com on 6/30/23). Review of the Treatment Administration Record (TAR) for April 2023 showed wound care to the left ankle was not performed on 4/5, 4/10, 4/11, 4/21, 4/24, 4/26, 4/27 and 4/29. The TAR for May 2023 showed wound care not performed on 5/9, 5/10, and 5/11. There was no documentation in resident #1's medical record explaining why wound care was not performed on those 11 days. Review of resident #1's Weekly Pressure Wound Evaluation form dated 5/08/23 described the wound on the left ankle as worsening. 2. Review of resident #5's medical record revealed he was admitted to the facility on [DATE] with diagnoses including osteomyelitis of the right ankle and foot, quadriplegia, and failure to thrive. Review of resident #5's quarterly MDS assessment dated [DATE] revealed a BIMS score of 13 which indicated intact cognition. The assessment showed resident #5 had one Stage 2 and one Stage 3 pressure ulcers. A stage 2 pressure injury is a partial-thickness loss of skin with exposed dermis. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. (Retrieved on 6/30/23 from www.npuap.org). Review of resident #5's medical record revealed a care plan for actual skin breakdown related to one Stage 3 pressure ulcer of the right heel and one Stage 2 pressure ulcer of the coccyx revised on 6/07/23. Interventions included to perform Wound care as ordered, see current treatment record and physician's orders; monitor effectiveness of / response to treatment as ordered. Review of resident #1's physician orders revealed the following wound care orders: *Coccyx - Cleanse with wound cleanser, pat dry apply zinc oxide paste and leave open to air every day shift dated 5/23/23. *Right heel - Cleanse with wound cleanser, pat dry apply honey fiber to wound bed secure with border foam daily every day shift dated 6/08/23. Review of the TAR for June 2023 showed wound care was not performed on the right heel on 6/14 and on the coccyx on 6/8, 6/9 and 6/14. There was no documentation in resident #5's medical record explaining why wound care was not performed those days. On 6/19/23 at 5:00 PM, Licensed Practical Nurse (LPN) A stated she was the wound care nurse and she performed wound care for residents with all wounds except skin tears. She indicated her responsibilities included rounding with the wound care physician weekly, identifying newly admitted residents with wounds, and entering and implementing new wound care orders. Later at 6:52 PM, LPN A explained she misunderstood whose responsibility was to document the wound care performed. She stated there were days she did not document the wound care she performed as she thought it would be done by the 105464 Page 2 of 3 105464 06/19/2023 Anchor Care & Rehabilitation Center 1515 Port Malabar Blvd NE Palm Bay, FL 32905

F 0686 nurse assigned to the resident. Level of Harm - Minimal harm or potential for actual harm On 6/19/23 at 6:49 PM, the Director of Nursing (DON) stated she was made aware wound care was not always documented when a nurse brought it to her attention during a Standards of Care meeting a few weeks ago. She explained the nurse asked if she was supposed to sign off for wound care performed by the wound care nurse. The DON indicated she educated LPN A and the nurses whoever performed the wound care signed it as done on the TAR. There was no evidence of the education provided. The DON acknowledged there was no evidence in residents #1 and #5's medical records showing the wound care was performed or residents refused the treatments on the above noted days. She stated nurses were expected to document the wound care performed and follow the physician's orders. Residents Affected - Few The facility's Wound Treatment Management policy and procedure revised on 11/23/22 read, To promote wound healing of various types of wounds, it is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physician orders. The form revealed guidelines for the nurses to follow which included, The facility will follow specific physician orders for providing wound care. Treatments will be documented on the Treatment Administration Record or in the electronic health record. The facility assessment dated [DATE] read, Staff are trained on policies and procedures, consistent with their roles. 105464 Page 3 of 3