Health inspection·April 26, 2024

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to identify, assess, and treat a post-surgical wound site for 1 of 3 residents (R1) reviewed for wounds in the sample of 9. This failure resulted in R1's wound site becoming infected, requiring a 10-day course of antibiotics, and at least four weeks of wound care treatment. Residents Affected - Few The findings include: R1's Face Sheet printed 4/26/24 shows she was admitted to the facility on [DATE]. R1's Nurse Practitioner's (NP) Progress Notes dated 2/8/24 at 9:51 AM show R1 is status post tracheostomy and PEG (feeding) tube placement on 1/31/24. R1's Progress Notes show the Wound Care Nurse's, V4, note dated 2/8/24 at 2:16 PM shows R1's admission skin assessment was complete. No wound to R1's right clavicle/neck was documented. On 2/20/24 at 5:28 PM, Respiratory Therapy documentation shows redness was noted on R1's right side next to her stoma (tracheostomy) site with an embedded suture in the skin. Nursing notes dated 2/20/24 at 7:33 PM show R1 has a wound to her right front neck with a scant amount of serous drainage, reddened skin, and no odor. Nursing notes dated 2/21/24 at 1:42 AM show R1 has antibiotic therapy in progress for an infection to her stoma trachea site. On 2/21/24 at 12:03 PM, V4 (Wound Care Nurse) documents that she was informed of an embedded suture to R1's neck under R1's trachea collar. V4 assessed the area and describes some redness to the area with serosanguineous drainage, no odor, and no signs of pain. V4 removed the suture, informed the wound care physician, and initiated a care plan related to the wound. R1's Physician Order Report for 2/7/24 to 4/26/24 shows an antibiotic was ordered on 2/20/24, discontinued on 2/22/24, and reordered on 2/22/24 for a diagnosis of infection to the right clavicle area to be given twice a day from 2/20/24 to 3/1/24. The same order report also show R1 is to receive tracheotomy care every morning from 2/7/24 to 2/27/24. Wound care treatments were ordered to R1's neck/clavicle area beginning on 2/21/24 to 2/27/24 and again from 3/11/24 to 3/27/24. R1's Progress Notes show R1 was sent to the hospital (for unrelated concerns) on 2/27/24 and was readmitted to the facility on [DATE]. R1' Care Plan initiated on 2/21/24 shows R1 has signs and symptoms related to right clavicle area wound infection and is currently on an antibiotic. Page 1 of 2 145211 145211 04/26/2024 Thryve of Burbank 5400 West 87th Street Burbank, IL 60459

F 0684 Level of Harm - Actual harm Residents Affected - Few V14 (Wound Care Physician) documented on 2/23/24 in R1's Wound Evaluation & Management Summary a post-surgical wound to R1's trachea site describing that a suture came out of the trachea site. V14 ordered wound care treatments to the area three times a week for 30 days. V14's Wound Evaluation & Management Summary documentation from 3/29/24 shows R1's post-surgical wound (as described above) was resolved on 3/29/24. R1's NP note dated 2/25/24 at 12:53 PM shows R1's physical exam shows a right clavicle/neck area with embedded suture with wound around site that has mild erythema (redness) and some non-odorous serosanguineous drainage (thin, watery, pink-tinged). The assessment/plan from that note is Infected Wound, initiate antibiotics twice a day for 10 days. On 4/26/24 at 10:44 AM, V5 (Respiratory Therapist/RT) said respiratory does trachea care every day on each resident with a trachea. Trachea care includes changing the gauze, cleaning the stoma and area around it, and suctioning. V5 said sometimes the initial trachea is sutured in place and sutures usually stay in about 14 days. V5 said RT found R1's suture embedded in her skin to the right of her stoma on 2/20/24. V5 said the RT should have been able to see the suture with daily trachea care. V5 said she could have removed the suture, but it was embedded, and she noted some redness and drainage. V5 said she was concerned it could be infected, so she told nursing about it. On 4/26/24 at 12:00 PM, V4 said R1 was admitted with two sutures: one on each side of her trachea plate. V4 said RT asked her to remove the sutures. V4 said R1's right side suture was embedded in her skin and looked puffy, a little red, and had some serosanguinous drainage. V4 said R1 was put on antibiotics to treat it for infection. V4 said RT should have identified the sutures and informed wound care about them. V4 said surgical wounds usually have sutures in place for two weeks. V4 said she does not know how long trachea sutures are left in place, but they should be removed before they become embedded in the skin. 145211 Page 2 of 2