Health inspection·March 15, 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 interview and record review the facility failed to identify a pressure injury before becoming unstageable and failed to provide treatment to moisture associated dermatitis. These failures resulted in R4 developing an unstageable pressure injury to the sacrum. This applies to 1 of 4 residents (R4) reviewed for pressure injuries in the sample of 11. Residents Affected - Few The findings include: On 3/15/24 at 11:34 AM, V10 Wound Licensed Practical Nurse (LPN) said R4 has pressure injury on her sacrum that was acquired at the facility and has been treated for a while. V10 said she is new to the facility and was not here when R4's wound was found. V10 said nursing staff does daily skin checks on residents during care and showers. V10 said she does weekly skin assessments for residents with wounds. V10 said any skin issue noted should be reported to the nurse and an assessment of the wound including measurements should be done and documented. V10 said interventions including treatments will then be implemented. R4's admission Skin assessment dated [DATE] shows R4 was admitted on [DATE] with blanchable redness to her sacrum and shows R4 is at very high risk for skin impairment. R4's admission Skin assessment dated [DATE] was done by V13 Previous Wound LPN and shows skin intact. R4's Care Plan dated 12/11/23 shows resident has activity of daily living self-care performance deficit related to general weakness post hospitalization, cerebral infarction due to thrombosis of middle cerebral artery, hemiplegia and hemiparesis following cerebral infarction affecting Right dominant side, altered mental status; requires assist of 2 staff members for bed mobility and transfers; incontinent of bowel and bladder; and is at risk for skin impairment. R4's Progress Note dated 12/11/23 by V13 shows skin intact. R4's Physician Note dated 12/13/23 shows Skin Common normals: no wounds. R4's Shower Sheet dated 12/17/23 shows R4's left buttocks is circled and labeled discolored. R4's Shower Sheet dated 12/20/23 shows R4's lower right and left buttock is circled and labeled 7 (indicating scratch per the assessment key). R4's Progress Notes from 12/14/23 to 12/27/23 does not contain progress notes or weekly skin Page 1 of 2 145623 145623 03/15/2024 Arcadia Care Morris 1095 Twilight Drive Morris, IL 60450

F 0686 Level of Harm - Actual harm Residents Affected - Few assessments on R4's skin. R4's Weekly Skin Observation Progress Note dated 12/28/23 shows new wound noted. Wound 1 was acquired in-house. Wound 1 is a pressure injury. Wound 1 is unstageable. First observation for wound 1. No reference prior. R4's Treatment Administration Record (TAR) for December 2023 shows an order dated 12/22/23 Cleanse open area to right buttock with normal saline, pat dry and apply duoderm. Every day shift for right buttock and an order dated 12/22/23 Cleanse open area to left buttock with normal saline, pat dry and apply duoderm. Every day shift for left buttock. These orders were discontinued on 12/26/23. From 12/22/23 to 12/26/23 the treatment orders for the left and right buttock were only checked off as completed 2 days (12/24/23-12/25/23). New orders for the right and left buttock were started on 12/26/23. (R4 had no treatments completed on her right and left buttock 12/26/23 and 12/27/23.) R4's Skin-Pressure/Diabetic/Venous/Arterial Wound Report dated 12/28/23 by V13 shows R4 has a new wound to her coccyx, acquired in-house, Unstageable Pressure injury with measurements of 5.5 x 6.4 x 0.1 Centimeters. Tissue type: 60% necrotic, 10% slough, 30% granulation. R4's Initial Wound Evaluation and Management Summary dated 12/28/23 by V14 Wound Doctor shows Unstageable (due to necrosis) sacrum pressure measuring 5.5 x 6.4 x 0.1 centimeters, thick adherent black necrotic tissue 30%, thick adherent devitalized necrotic tissue 30%, slough 10%, granulation tissue 30%. R4's Wound Evaluation and Management Summary dated 1/15/24 by V14 Wound Doctor shows Addendum to previous visit note from 1/8/24: wound was not present on admission to facility. On 3/15/24 at 1:51 PM, V2 Director of Nursing said V13 was the wound care nurse at the time R4's wound was found. V2 said V13 no longer works here. V2 said she was not sure how R4's unstageable wound happened between 12/21/23 and 12/28/23. V2 said it is not typical for a wound to develop so quickly. V2 said absolutely the wound should have been identified before being unstageable. V2 said on 12/21/23, V13 noted open areas on the TAR but there were no measurements done or assessment charted, but the care plan indicated Moisture Associated Skin Damage (MASD). V2 said other than the shower sheets, she could not find any other skin assessments or notes. V2 said MASD makes a resident as risk for developing pressure. V2 said R4's treatments for the MASD or open skin areas on the left and right buttock were not completed as ordered on the TAR. V2 said not doing the treatments as ordered increases the risk of developing pressure injuries also. V2 said when R4's pressure wound was found it was one large area indicating the areas on the left and right buttocks turned into the large sacral wound. The facility's Pressure Injury and Skin Condition Assessment Policy dated 11/2023 shows Each resident will be observed for skin breakdown daily during care. Changes shall be promptly reported to the charge nurse who will perform the detailed assessment. Care givers are responsible for promptly notifying the charge nurse of skin breakdown. The initial observation of the ulcer or skin breakdown will also be described in the nursing progress notes. Dressing will be checked daily for placement, cleanliness, and signs and symptoms of infection. 145623 Page 2 of 2