Health inspection·April 23, 2024

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to follow the Physician's orders for wound treatment (Resident #4), and failed to obtain a physician order for wound care (Resident #5), for 2 of 3 sampled residents reviewed for wound care (Residents #4 and #5). Residents Affected - Few The findings included: 1) Review of Resident #4's clinical record documented an admission to the facility on [DATE] and a readmission on [DATE]. The residents diagnoses included Non-Traumatic Intracerebral Hemorrhage, Encephalopathy, Unsteadiness on Feet, Diabetes Mellitus and Unspecified Open Wound, Lower Leg. Review of Resident #4's Minimum Data Set (MDS) quarterly assessment dated [DATE] documented a Brief Interview of the Mental Status (BIMS) score of 14 indicating that the resident had no cognition impairment. The assessment documented under Functional Abilities and Goals that the resident was dependent on the staff to complete most the activities of daily living except eating. Review of the resident's care plan titled (Resident name) has impaired skin integrity. Potential for further breakdown . initiated on 05/19/22 and revised on 05/25/23 documented an intervention that read .wound treatment as ordered . Review of Resident #4's physician order dated 01/19/24 documents cleanse with normal saline open area to left lower leg shin, apply Xeroform dressing every other day. On 04/23/24 at 9:13 AM, observation revealed Resident #4 in his room sitting in a motorized wheelchair. An interview was conducted with the resident who voiced no concerns and that his leg dressing was changed daily. Observations revealed a dressing on the resident's left lower leg, partial covered by a splint. On 04/23/24 at 9:16 AM, a side by side observation of Resident #4's left lower leg dressing was conducted with Staff A, Certified Nursing Assistant (CNA). The observation revealed the resident's dressing was dated 04/18/24. Photographic evidence obtained. On 04/23/24, at 10:50 AM, a side by side observation of Resident #4's left lower leg dressing was conducted with the Wound Care Nurse (WCN). The observation revealed the resident's dressing was dated 04/23/24. The WCN stated the floor nurse were responsible to do Resident #4's left lower leg dressing changes. Subsequently, the photographic evidence was presented to the WCN. On 04/23/24 at 10:57 AM, an interview was conducted with Staff B, Registered Nurse (RN) who stated Page 1 of 2 106038 106038 04/23/2024 Alexander "sandy" Nininger State Veterans Nursing 8401 W Cypress Dr Pembroke Pines, FL 33025

F 0684 Level of Harm - Minimal harm or potential for actual harm she changed Resident #4's left lower leg dressing today. Staff B stated he had a scab on his left shin and she cleansed with normal saline and applied a xeroform dressing. Staff B acknowledged the resident's dressing was dated 04/18/24. Subsequently, a side by side review of the resident's physician order for the left lower leg dressing change was conducted with Staff B who stated the dressing was supposed to be changed every other day on the evening shift. Residents Affected - Few On 04/23/24 at 11:30 AM, during an interview, the Director of Nursing (DON) was apprised of Resident #4's left lower leg dressing change not done as per physician orders. A side by side review with the DON of the resident's Treatment Administration Record (TAR) revealed that it was documented that the resident's dressing was changed on 04/20/24 and on 04/22/24. Photographic evidence of Resident #4's dressing dated 04/18/24 was presented to the DON. 2) Review of Resident #5's clinical record documented an admission on [DATE] and a readmission on [DATE]. The resident diagnoses included Atrial Fibrillation (A-Fib), Diabetes Mellitus, Venous Insufficiency (Peripheral), Cellulitis of Left Toe, Localized Swelling, Acute Osteomyelitis, and Open Wound of Left Foot. Review of Resident #5's MDS quarterly assessment dated [DATE] documented a Brief Interview of the Mental Status (BIMS) score of 15 indicating the resident had no cognition impairment. The assessment documented under Functional Abilities and Goals that the resident was dependent on the staff to complete most of the activities of daily living. Review of Resident #5's care plan titled (resident's name) risk for skin breakdown initiated on 02/21/20 and revised on 04/17/24 documented an approach start date 02/21/20 as to monitor skin for signs and symptoms of further breakdown or changes .topical treatment as ordered .wound/skin treatment as ordered, monitor site for changes . Review of Resident #5's clinical record lacked evidence of a written physician order for the resident's left shin dressing. On 04/23/24 at 9:55 AM, a side by side observation of Resident #5's wound dressing was conducted with the Wound Care Nurse (WCN). Observation revealed the resident had a dry gauze over his left shin with no date printed. The WCN was asked to remove the dressing and revealed a Xeroform gauze underneath the dry gauze. The WCN stated that the resident had a skin tear to the shin and that the floor nurses are responsible to do skin tear care and dressing changes. The WCN added she was not aware of the resident's skin tear to the shin. The WCN was asked to submit Resident #5's physician order for the left shin skin tear Xeroform treatment and stated there was not a physician order for the skin tear. On 04/23/24 at 11:35 AM, during an interview, the DON was apprised of Resident #5's left shin skin tear with an undated dressing and without a physician order for treatment. On 04/23/24 at 2:39 PM, an interview was conducted with Staff C, RN who stated that she was not aware of Resident #5's skin tear dressing on his left shin. The RN stated an order for the left shin skin tear was obtained today. 106038 Page 2 of 2