Health inspection·January 3, 2024

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to assess and identify a resident's pressure injury to her right lower leg until it was a stage 3 acquired pressure injury from a medical device. This applies to 1 of 3 residents (R2) reviewed for acquired pressure injuries in the sample of 3. Residents Affected - Few This resulted in R2 sustaining a facility acquired stage 3 pressure injury. The findings include: R2's face sheet shows R2 is [AGE] year old who was originally admitted to the facility on [DATE], with diagnoses that include right femur fracture that had undergone hip surgery, history of falling, and diabetes. , R2's Braden scale (predicting pressure score risk), dated 10/30/23, shows R2 is at risk for developing pressure. R2's skin admission assessment, dated 10/11/23, shows R2 had no pressure injury except a surgical incision to right hip. R2's hospital Discharge summary, dated [DATE], shows an order for R2's right lower extremity to be non weight bearing, and the knee immobilizer to be on at all times. R2's care plan, dated 10/12/23, shows R2 was at risk to develop further skin breakdown, but did not include R2's use of the immobilizer or any care that needs to be done when wearing a knee immobilizer. R2's Wound Evaluation Management Summary, dated 11/1/23, was when R2's pressure injury was discovered to her right lower lateral calf that was a stage 3 measuring 6.5 centimeters (cm) x 2.5 cm x 0.1 cm. The Facility Wound Report, dated 1/3/23, provided to this surveyor shows R2's facility acquired pressure injury to her right lower lateral calf was now a stage 4 measuring 3.5 cm x 1.0 cm x 0.1 cm . On 1/3/24 at 10AM, R2 was in bed on a low air loss mattress. R2's right leg was suspended with a pillow. R2 said she fell at home, hurt her right leg, and had surgery. R2 said she now has a wound at the back of her right leg, but cannot recall what happened. V4 (Wound Nurse), who was also in R2's Page 1 of 2 145602 145602 01/03/2024 Village at Victory Lakes, The 1055 East Grand Avenue Lindenhurst, IL 60046

F 0686 Level of Harm - Actual harm Residents Affected - Few room, showed this surveyor R2's pressure injury to right lower lateral calf. A huge open wound was noted at the back of R2's right lower leg. V4 said R2's acquired pressure injury came from R2's knee immobilizer (medical device) she was using before. V4 then opened a closet, took a knee immobilizer, and showed this surveyor that this was R2's knee immobilizer. The knee immobilizer has velcro on the side. V4 pointed a hard area at the back part of the immobilizer, and said R2's right lower leg was laying directly on the hard part of the immobilizer; that had caused pressure injury on R2's right lower leg (calf). V4 said R2 was complaining of discomfort to that area. V4 said when the immobilizer was removed to check the skin, V4 had a stage 3 open area to her right lower leg V4 said the order was for R2 to use the immobilizer at all times, but typically, the skin can be checked during care. On 1/3/24 at 10:20 AM, V6 (Wound Doctor) said she took over R2's wound care for the past 4 weeks now. V6 said, (R2) has fragile skin and is also a diabetic. Wearing a knee immobilizer has the potential risk to cause the development of pressure injury. Slight movements can cause the immobilizer to move that can cause skin frictions. V6 said it was important to check the placement of the immobilizer and inspect the skin underneath. On 1/3/24 at 2PM, V2 (Director of Nursing) said since the order of the knee immobilizer was on at all times, no one was checking the skin underneath. V2 also said the order was not clarified to the Ortho if it can be removed for skin checks. V2 also confirmed R2's immobilizer was not part of R2's Physician Order Sheets (POS). On 1/3/24 at 2:15 PM, V7 ( R2's previous Wound Doctor) said, (R2) had an order of wearing the immobilizer at all times from Orthopedic, but generally speaking, when a resident wears an immobilizer, staff has to check the skin from time to time as immobilizer can cause pressure or skin irritations. The facility presented a document entitled Unavoidable Pressure Injury clinical condition, dated 1/4/24. The facility also presented a document from the Orthopedic MD, dated 1/4/24, that R2 has to wear the knee immobilizer until 11/13/23. 145602 Page 2 of 2