Health inspection·January 31, 2024

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 observation, interview, and record review, the facility failed to ensure a physician-ordered negative pressure wound treatment system (wound vac) was placed for a resident with stage 4 pressure ulcers and failed to ensure a resident's stage 4 pressure ulcer was covered. Residents Affected - Few This applies to 2 of 3 residents (R1, R2) reviewed for pressure ulcers. The findings include: 1.R1's Face Sheet showed she is a [AGE] year-old resident who was initially admitted to the facility on [DATE]. R1's progress notes showed she was sent to the hospital on 1/17/2024 to facilitate antibiotic treatment due to osteomyelitis and the lack of progressive healing of her wounds. R1's diagnoses include cerebral palsy, severe protein-calorie malnutrition, anorexia nervosa, pressure ulcer of sacral region stage 4, pressure ulcer of right buttock, stage 4 osteomyelitis, and adult failure to thrive. R1's 1/11/2024 Minimum Data Set (MDS) showed her cognition is moderately impaired. R1's Resident Face Sheet showed she was re-admitted to the facility on [DATE]. R1's January 2024 Physician Order Report showed 1/21/2024 orders for wound vac placement with negative pressure of 125 continuously to her right buttock and sacrum, with special instructions of when seal is broken disconnect wound vac and apply a wet to moist dressing and cover with a dry dressing. The Report showed these orders were discontinued on 1/24/24 (during the survey), then restarted on 1/29/24. On 1/23/2024 at 11:53 AM (two days after R1's re-admission), R1 was in bed. R1 had severe contractures to all her extremities and was unable to move herself. Her wound vac machine was on top of her nightstand, turned off, and not attached to her wounds. Two boxes of available wound vac supplies were on R1's floor. On 1/24/2024 at 10:15 AM (three days after R1's re-admission), R1 was in bed and the wound vac machine was still turned off on her nightstand and still not in use. V5 (Registered Nurse/Wound Nurse from a sister facility) came to do the wound care. V5 removed a dressing that had been in place. On 1/24/24 at 2:25 PM, V6 (Wound Physician) stated if the wound vac seal is broken, or the wound vac is not available, there are alternate orders. V6 stated the wound vac was ordered for controlling drainage and helping with wound granulation. V6 stated R1 should have the wound vac hooked up and functioning and should not be without it for more than two hours. Page 1 of 2 145901 145901 01/31/2024 Lemont Nursing & Rehab Center 12450 Walker Road Lemont, IL 60439

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few The negative pressure wound treatment system's undated Quick Reference Guide showed Indications for use- the [brand name] is indicated for use in patients who would benefit from negative pressure wound therapy as the device may promote wound healing by the removal of excess exudates, infectious material and tissue debris . The Guide further showed The [brand name] should remain on for the duration of the treatment. If the patient must be disconnected, the ends of the tubing should be protected using the tethered cap. The length of time a patent may be disconnected for the [brand name] is a clinical decision based on individual characteristics of the patient and the wound. Factors to consider include the location of the wound, the volume of drainage, the integrity of the dressing seal, the assessment of bacterial burden and the patient's risk of infection . The facility's January 2017 Pressure/Skin Breakdown Clinical Protocol showed 7. The Physician will authorize pertinent orders related to wound treatments, including pressure redistribution surfaces, wound cleansing and debridement approaches, dressings (occlusive, absorptive, etc.), and application of topical agents . 2. R2's Face Sheet showed R2 is a [AGE] year-old resident admitted to the facility on [DATE] and opted for hospice services on 1/18/24. R2's Face Sheet showed diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, and pressure ulcer of sacral region, stage 4. R2's 11/24/23 MDS showed his cognition is severely impaired. On 1/23/24 at 1:22PM, V2 DON (Director of Nursing) provided wound care for R2's sacral wound with the help of V3 CNA (Certified Nursing Assistant). When V2 opened R2's incontinent brief, no wound dressing was in place or was noted having fallen off in the brief. R2's wound bed was pale and without any granulation tissue. On 1/23/24 at 1:30 PM, V3 stated when V3 changed him 30 minutes earlier there was no dressing in place. V3 stated she did not know how long R2 was without a wound dressing because she did not assist R2 out of bed that morning. R2's January 2024 Physician Order Report showed a 1/17/2024 order for Site Sacrum: Cleanse area with [normal saline] pat dry, apply calcium alginate and cover with dry dressing daily and as needed. Once A Day 06:30 AM - 02:30 PM. 145901 Page 2 of 2