Health inspection·July 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 assess, treat and monitor a skin alteration of a newly admitted resident. The facility also failed to document these skin alterations on the discharge orders and summary. This applies to one of four residents (R1) reviewed for pressure sores on the sample list of four. Residents Affected - Few The findings include: R1, a [AGE] year-old female admitted to the facility from hospital on 1/1/2023. R1's diagnoses included but not limited to strain of muscle fascia, tendon of left hips, injury to the head, repeated falls, muscle weakness, difficulty walking, bilateral osteoarthritis of hip, hyperlipidemia, dementia with psychotic disturbance, psychosis, major depressive disorder, and vascular dementia. R1 was residing from assisted living facility prior to being hospitalized , then was admitted to the facility for deconditioning. R1 was discharged on 1/17/2023 and was back to the assisted living facility on 1/17/2023. The MDS (Minimum Data Set) dated 1/15/2023 shows that R1's cognition was severely impaired and required extensive assistance with ADL (Activities of Daily Living) along with mobility and transfer. The MDS shows that R1 was not identified with pressure ulcer but was identified as risk for pressure sore development. The admission assessment dated [DATE] shows that R1 was identified with skin impairments that included bruising on left arm from history of recent falls, and unopened redness on sacrum. The admission assessment did not include a comprehensive assessment of the redness on R1's sacral area. Review of the EHR (Electronic Health Record) shows that there was no follow up to assesses the redness to R1's sacrum The EHR was reviewed with V1 (Administrator) and V4 (Wound Care Nurse) on 7/17/2023 at 2:30 P.M and they confirmed the lack of assessment to the sacral area. V1 and V4 added that the sacral area should have been comprehensively assess and monitored to ensure correct treatment was provided. Review of the ETAR (Electronic Treatment Administration Record) for the month of January 2023 shows that there was a checkmark that R1 skin was check during shower days which was Mondays and Thursdays. There was no documentation of the result of the skin check to show the condition of R1's skin. On 7/18/2023 from 10:37 P.M. to 2:30 P.M. at an intermittent time; the following staff V9, V10, V11 (Licensed Practical Nurses/LPNs) and V12, V13 (Certified Nurse assistants/CNA) were interviewed. They said that the hall has mostly taken care of R1 while R1 was at their facility. They all said that Page 1 of 2 145219 145219 07/19/2023 Burgess Square Healthcare Ctr 5801 South Cass Avenue Westmont, IL 60559

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few it is the facility's practice to ensure skin check was done every shift from head to toe and that included R1. They also said that they do not remember R1 if she had pressure ulcer. The care plan initiated 1/2/2023 with revision date of 1/26/2023 shows that R1 was admitted with redness to her sacrum and bruising from her fall and at risk for further skin impairments related to required ADLs (Activities of Daily Living) care assist, recent hospitalization, decreased mobility, bladder and bowel incontinence. The interventions did not include specific plan of care and treatment that would address the redness of R1's sacral area. The general skin care interventions included monitoring pressure areas and provide regular skin assessments on shower days. The discharged summary date 1/17/2023 did not show any documentation regarding any R1's altered skin. Review of R1's record form the assisted living facility shows that R1 was admitted on [DATE] at approximately 1:17 P.M. The admission report documented by V6 (Registered Nurse/RN) shows that R1 has redness to the buttocks/sacral area. The admission record also shows that R1 has a fluid filled blister to the right heel. This was confirmed by interview with V6 on 7/18/2023 at 9:00AM. On 7/18/2023 at 10:37 A.M., V5 (Director of Nursing form the Assisted Living) said that R1 was readmitted to their facility (Assisted Living) with a pressure ulcer as stage I to the buttocks and sacrum and stage II to the right heel. On 7/18/2023 at 9:45 A.M., V7 (RN/Home Health Nurse) said that R1 was readmitted to the assisted living facility with a pressure ulcer to the sacrum/buttocks and right heel. The facility's undated policy for wound management shows: Any resident with a wound receives treatment and services consistent with resident's goals of treatment. Typically, the goal of treatment is one of promoting healing and preventing infection. Pressure ulcer is any lesion caused by unrelieved pressure that results to damage to underlying tissue .Stages of pressure ulcer: Stage I, an intact skin with non-blanchable redness of a localized area usually over a bony prominence: Stage II, is a partial thickness loss of dermis presenting a shallow open ulcer, with red/pink wound bed, May also present as an intact skin or open /ruptured serum filled blisters. The policy also shows that Wound Assessment and Management is done at time of admission (same shift) and if not possible within 24 hours. The admission wound assessment should include physical evaluation of the resident that include the skin alteration that was present on admission, skin discoloration, and any evidence of scarring on pressure points. A head-to-toe assessment need to be done, comprehensive assessment that includes location, length, width, appearance of edges. The assessment should be documented in the resident's medical record. The facility's policy dated July 2018 for skin monitoring shows: The purpose of the policy and procedure is to determine if a patient has any skin integrity issues upon admission and throughout their stay in the facility. This procedure includes the measures taken to monitor a patient's skin integrity, identify any impairments in skin integrity and ensure the appropriate interventions are in place to protect the skin. Skin checks should be done at the following times: a. Upon admission by the nurse b. Daily by the PCTs (Primary Care Technician) c. Twice per week during showers and PRN by nurse. PCT's will mark any skin observations present in Point of Care under the Skin Observation task. Any skin observations will be reported to the nurse for additional assessment. 3. Once observation of patient skin is assessed on shower day, the nurse will document that the skin observation has been completed and sign off in the TAR (Treatment Administration Record). 145219 Page 2 of 2