Health inspection·December 14, 2023

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure treatments were completed as ordered for a resident with pressure injuries for 1 of 3 residents (R2) reviewed for pressure in the sample of 3. Residents Affected - Few The findings include: R2's Physician Orders (POS), dated 12/1/23, shows sacrum wound: cleanse with normal saline, pat dry, apply silver gel, cover with bordered foam dressing every day shift and as needed. The same POS shows an order dated 12/14/23 for sacrum wound: cleanse with normal saline, pat dry, apply santyl ointment to wound bed, cover wound bed with calcium alginate, cover with bordered foam dressing every day shift and as needed. R2's Wound Nurse Practitioner Noted, dated 12/11/23, shows sacrum pressure treatment recommendations: 1. cleanse with normal saline 2. apply santyl and calcium alginate to base of the wound. 3. secure with bordered foam. 4. change daily and as needed. R2' Progress Note, dated 12/14/23, at 8:15 AM, shows patient urinary catheter was removed in the morning at 5:30 AM because it was leaking and tried to reinsert it, but it failed, no urine retained. On 12/14/23 at 9:34 AM, R2 was in bed finishing breakfast. R2 said she had a wound on her bottom that she got in the hospital. R2 said she was not sure if there was a dressing on her wound or not, because she had a big mess overnight. R2 said her catheter was leaking everywhere and they had to clean her up. R2 said everything was saturated including her gown and the bedding under her, so they cleaned her up and got new bedding. R2 said the Certified Nursing Assistant (CNA) cleaned her up and the nurse took out the catheter and was having trouble putting in a new catheter, so they just put a brief on her. R2 said the nurse told her the wound nurse would change the dressing later that morning. R2 said this was around 5:00 AM that all this happened. At 9:45 AM, V5, CNA, assisted R2 to roll to her side and lowered R2's incontinence brief. R2's dressing was so saturated it was unattached and fell off into the incontinence brief, which contained urine and stool. R2's dressing was completely saturated with bloody brownish material. R2's wound had stool in it. V5 cleaned R2, and V3, Registered Nurse, changed R2's dressing. V3 said the nurse should have changed the dressing this morning when they cleaned R2 up from her catheter leaking. V3 cleaned the wound with normal saline and applied silver gel, and then a bordered foam dressing. On 12/14/23 at 11:37 AM, V5, Wound Care Director, said R2 has an unstageable sacral wound. V5 said if a dressing is saturated or falling off, the dressing needs to be changed as soon as possible. V5 said there is a risk for infection in the wound if a dressing is saturated with urine and or stool and not changed right away. V5 said the nurse should have changed the dressing herself, and not Page 1 of 2 145593 145593 12/14/2023 Avantara Libertyville 1500 South Milwaukee Avenue Libertyville, IL 60048

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few waited for the wound care nurse to do it later. V5 said R2's treatment order changed when the wound doctor saw her on 12/11/23 to santyl and calcium alginate to wound and cover with dressing. V5 said R2's previous treatment was the silver gel, and she had forgot to put the new treatment order in the computer. The facility's Pressure Ulcer Policy, dated 3/23 shows, to provide care and services to prevent pressure injury development and to promote the healing of pressure injuries/wounds that are present. 145593 Page 2 of 2