Health inspection·March 25, 2021

C1005 T22 DIV5 CH3 ART3-72315(f) (4)(5)(6)(7) Nursing Service-Patient Care The facility failed to assess, treat, document, follow a nursing care plan, and provide necessary nursing services to one of three residents (Resident 1) to prevent, identify and promote healing of a pressure wound. As a result, Resident 1 developed a pressure wound classified as a Stage 1 (redness on skin without breakdown) which progressed to a Stage 3 (Full thickness tissue loss) in a week, causing physical harm to Resident 1. Resident 1 was admitted to the facility on 11/10/18, with medical diagnoses including Acquired Absence of Right Leg Below Knee, and Chronic Obstructive Pulmonary Disease (A chronic inflammatory lung disease that causes obstructed airflow from the lungs), according to the facility Face Sheet (Facility demographic). Resident 1's MDS (Minimum Data Set-A clinical assessment) dated 12/24/18, indicated his BIMS (Brief Interview of Mental Status-A cognition evaluation) score was a 10, which indicated his cognition was moderately impaired. Resident 1's MDS also indicated he required extensive assistance from one person for bed mobility, toilet use and locomotion on the unit. Resident 1's admission assessment titled, "ADMISSION/RE-ADMISSION-RESIDENT DATA COLLECTION," dated 11/10/18 at 9:11 p.m., indicated Resident 1 had no pressure injuries other than blanchable redness (When the skin turns white when pressed, and red when the pressure is removed) to his coccyx (A triangular bony structure located at the bottom of the vertebral column) area. A Nursing Plan of Care initiated on 11/12/18, indicated Resident 1 had potential for impaired skin integrity. Interventions to prevent impaired skin integrity included observing Resident 1's skin integrity every shift during ADL (Activities of Daily Living) care, repositioning every two hours and having him use a pressure-reducing cushion while up in his wheelchair. A facility document titled, "WEEKLY ASSESSMENT," dated 12/26/18 at 2:15 p.m., indicated Resident 1's skin was, "Free of any open areas." This document also indicated Resident 1 was incontinent of bowel. Pressure Ulcer, Stage I: Nurses notes documented by Licensed Nurse A, dated 12/26/18 at 4:36 p.m., indicated, "Daughter also noted that scrotum (Part of the male external genitalia) was enlarged, scattered redness to peri (Perineum-The area between the anus and the scrotum) area and buttocks, and Stage 1 ulcer to left hip." A dietician note dated 12/26/18 at 2:55 p.m., stated, "Per nursing, [Resident 1] was noted with an open area today," indicating the wound was open. During a concurrent interview and record review with the Director of Nursing (DON) on 2/03/21 at 9:45 a.m., the DON confirmed no documentation was found in Resident 1's medical record describing, providing measurements of the wound or specifying if it was open on 12/26/18, when identified by Licensed Nurse A. The DON also confirmed there was no documentation indicating the physician was notified about the wound to the left hip. During an interview on 2/03/21 at 1 p.m., the DON stated Licensed Nurse A no longer worked for the facility. During a concurrent interview and record review with the DON on 2/03/21 at 9:55 a.m., the DON confirmed no documentation was found in Resident 1's medical record indicating a Nursing Plan of Care was created for treatment of the pressure wound identified on 12/26/18, on Resident 1's left hip. The DON also confirmed there was no documentation in Resident 1's medical record, of the wound to the left hip until 12/30/18 (4 days later), including documentation of nursing assessments or treatments provided to the injured area or nursing notes mentioning the injury to the left hip. Physician orders from 12/26/18 through 12/31/18, indicated there were no orders for treatment of the pressure wound, until 12/30/18. On 12/30/18, the physician ordered for application of Santyl (A prescription medicine used to treat dermal ulcers) to the open wound, followed by a dry dressing. A low air loss mattress was not ordered until 12/30/18, according to physician orders for December of 2018. During an interview with Resident 1's Family Member X, on 2/17/21 at 9:25 a.m., who discovered the injury, she stated, when the wound was first discovered in Resident 1's left hip, it was open, and had serosanguineous (Discharge that contains blood and yellow fluid) drainage coming out, corroborating the dietician's note on 12/26/18 at 2:55 p.m., which indicated the wound was open. Family Member X stated the night of the discovery of the pressure wound; she was changing Resident 1's briefs as he was soiled with feces, after waiting for a prolonged period of time for facility staff to provide him incontinence (Cleaning of the skin after an incontinent episode) care. Family Member X stated she believed the pressure wound was caused by metal screws on the facility-provided wheelchair that Resident 1 used. Family member X stated the metal screws on the wheelchair were exposed, and rubbed against the area where the pressure wound was discovered. Family Member X stated, although Resident 1 was supposed to have a cushion in the wheelchair, she had never seen Resident 1's wheelchair with the cushion prior to the discovery of the pressure wound. Family Member X stated she visited Resident 1 at the facility almost every day and did not see the cushion on several occasions. This cushion was part of his interventions for preventing skin impairment in his Nursing Care Plan initiated on 12/14/18. Family Member X described the wheelchair as blue in color, with dark blue plastic upholstery. During an interview with Resident 1's Family Member Y on 2/17/21 at 9:50 a.m., he stated he also believed the exposed screw heads on Resident 1's facility-provided wheelchair caused the pressure wound, as they came in contact with the exact area on the left hip where the pressure wound was discovered. Family Member Y stated he observed Resident 1 at least twice not having a cushion when up in his wheelchair, and the times he did have a cushion, the cushion was too small to cover the screw heads. Family Member Y also described the wheelchair as dark blue in color with screw heads exposed on the surface of the seating area. During an observation on 2/04/21 at 2:50 p.m., three facility's wheelchairs were observed. One wheelchair was noted to be dark blue in color, with plastic upholstery. The wheelchair had large screw heads exposed, and sticking out approximately 0.33 inches from the surface of the seat of the chair. A facility document titled, "WOUND-WEEKLY OBSERVATION TOOL," dated 1/01/19 at 1:34 p.m., described the different stages of wounds. Stage I was described as, "Intact skin with non-blanchable redness of a localized area usually over a bony prominence." Stage II was described as, "intact or open/ruptured serum-filled blister." During an interview with the DON on 2/03/21 at 9:55 a.m., he stated that if the wound was already open on 12/26/18, when first discovered, it should have been classified as a Stage II pressure wound, and not as a Stage I pressure wound as documented in the Nursing Note dated 12/26/18 at 4:36 a.m. Pressure Ulcer, Stage II A Nurses' Note documented by Licensed Nurse B dated 12/30/18 at 11:16 p.m., indicated, "[Family Member Y] noted that left hip was open wound, LN (Licensed Nurse) informed. LN assessed site to left hip measuring 2 x 1 cm (Centimeters), no s/sx (Signs/Symptoms) of infection. MD (Medical Doctor) informed." According to this Nursing Note, Resident 1's family member discovered and alerted staff of the pressure wound on his left hip for the second time, without facility staff identifying the wound during assessments. During an interview on 2/03/21 at 9:45 a.m., the DON stated Licensed Nurses were required to perform head to toe skin assessments every shift. A Nursing Plan of Care was created on 12/31/18, in regards to Resident 1's wound identified on 12/30/18, with interventions aimed at healing the wound, but the plan did not indicate Resident 1 was required to be repositioned every two hours, or provided frequent incontinence care. The care plan did not indicate Resident 1 was required to use a cushion while up in his wheelchair. This was confirmed by the DON during an interview on 2/03/21 at 9:58 a.m. During a concurrent interview and record review on 2/03/21 at 9:58 a.m., the DON confirmed Resident 1's wound, documented by Licensed Nurse B on 12/30/18 at 11:16 p.m., was described and measured, but not staged (Categorized based on the level of tissue injury). During a phone interview with Licensed Nurse B on 2/03/21 at 5:52 p.m., she confirmed identifying the pressure wound to Resident 1's left hip after Family Member Y told her about it, but confirmed she did not stage the wound. When asked for the reason for not staging the wound, she stated the DON had told licensed nurses at the facility to describe what they saw in their documentation, but not to stage pressure wounds, as that was a task assigned to the treatment nurses (Licensed Nurses who treat skin wounds). Licensed Nurse B was asked if she notified the treatment nurse. Licensed Nurse B stated it was not the facility's protocol to notify the treatment nurse, as she had already notified the physician of Resident 1's left hip wound. Licensed Nurse B also stated she did not notify the treatment nurse because she was working late in the evening when the pressure wound was discovered, and the treatment nurse was no longer at the facility at that time. During an interview with the DON on 2/04/21 at 3 p.m., he denied instructing Licensed Nurses not to stage pressure wounds, and stated Licensed Nurses were required to stage pressure wounds if they found them. During an interview with the Director of Staff Development (DSD) on 2/04/21 at 3:15 p.m., she stated she provided training to all Licensed Nurses on staging pressure wounds. The DSD also stated Licensed Nurses who found pressure wounds were required to notify Treatment Nurses, and if Treatment Nurses were no longer at the facility, they should leave them a note. A Nursing Note dated 12/31/18 at 1:45 p.m., indicated Family Member X decided to transfer Resident 1 to an acute care facility. Emergency Department notes from the Acute Care Facility dated 12/31/18 at 7:28 p.m., indicated, "EXTREMITIES: Right BKA (Below the knee amputation), left hip 2 cm stage II pressure ulcer with some mild erythema (Redness on the skin) surrounding it ... [Resident 1] is a 89 Y (Year) male with a developing left hip pressure ulcer from rubbing on a wheelchair, not apparently terribly infected. I do not suspect surrounding cellulitis (Bacterial skin infection) although there is likely a mild infection developing in the ulcer ...Current Discharge Medication List START taking these medications Bacitracin-Polymyxin B (Antibiotic ointment used to treat skin injuries) ...Apply to affected area(s) 1 to 3 times a day or as directed." Stage III Pressure Ulcer: A facility document titled, "WOUND-WEEKLY OBSERVATION TOOL," dated 1/01/19 at 1:34 p.m., indicated Resident 1 had an acquired, Stage III pressure wound to the left hip. This document described the wound as measuring 2 cm in length by 2 cm in width, moist, with scant serous drainage (Clear yellow fluid). During an interview with Treatment Nurse C on 2/03/21 at 1:10 p.m., she stated treatment of a pressure wound required incontinent care frequently, after each incontinent episode, frequent repositioning and assessment of incontinence care every two hours. A facility document titled, "Documentation Survey Report v2," which indicated the bowel and bladder care/incontinence care received by Resident 1 in December of 2018 and January 2019, had missing documentation for the evening shift of 12/16/18, 12/17/18, 12/27/18 and 12/28/18. There was also missing documentation for the night shift of 12/23/18, 12/26/18, 12/29/18 and 1/01/19. According to this document, each shift consisted of eight hours. There was no documented evidence Resident 1 received bowel and bladder/incontinence care during these eight shifts, including the night shift of 1/01/19, when the pressure wound Stage III to the left hip had already been discovered. During a phone interview with the DON on 2/17/21 at 1:30 p.m., he confirmed the missing documentation on the document titled, "Documentation Survey Report v2," dated December, 2018 and January, 2019. The DON stated Resident 1 used a Foley Catheter (A flexible tube that a clinician passes through the urethra and into the bladder to drain urine), which may have accounted for not documenting bladder care, but he stated not having an explanation for the missing documentation in general. When asked if he could determine if Resident 1 had received bowel and bladder/incontinence care during the shifts without documentation, the DON stated, "It's really hard for me to say that he [Resident 1] received it [bowel and bladder/incontinence care]." The facility policy titled, "Charting and Documentation," last revised in April of 2008, indicated, "All services provided to the resident, or any changes in the resident's medical or mental condition, shall be documented in the resident's medical records." The facility policy titled, "Change in Resident's Condition or Status," last revised in April of 2007, indicated, "Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition ...The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On-Call Physician when there has been: A discovery of injuries of an unknown source." The facility policy titled, "Care Plans-Comprehensive," last revised in August of 2006, indicated, "An individualized Comprehensive Care Plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological need is developed for each resident ...Care plans are revised as changes in the resident's condition dictate." The facility policy titled, "Pressure Ulcers/Skin Breakdown-Clinical Protocol," last revised in April of 2007, indicated, "the nurse shall assess and document/report the following: a. Vital signs b. Full assessment of pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissue ...The physician will help identify medical interventions related to wound management." The above violation had a direct or immediate relationship to the health, safety, or security of patients.