Health inspection·February 14, 2024

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 interview and record review the facility failed to notify the physician when a resident developed an unstageable pressure ulcer and failed to notify the physician and implement a new treatment order after a change in a pressure ulcer for 1 of 3 residents (R1) reviewed for pressure ulcers in the sample of 8. Residents Affected - Few The findings include: R1's Wound Assessment Details Report dated 2/3/24 shows that an unstageable pressure ulcer with necrosis measuring 3 centimeters (cm) x 3 cm was identified on 2/3/24. The wound had a moderate amount of serous drainage and no odor. R1's Nursing Notes dated 2/3/24 at 6:40 PM shows, Noted a pressure injury on [R1's] sacrum. Cleansed with NS (normal Saline), pat dried, and applied bordered foam Notified and explained treatment plan to POA R1's Treatment Administration Record (TAR) for February shows an order entered on 2/3/24 for, Treatment: Sacrum: Cleanse with NS, pat dry, and apply bordered foam every day shift every 3 days(s) for wound treatment. R1's Electronic Medical Record does not document that R1's physician was notified of the new pressure ulcer. On 2/14/24 at 2:02 PM, V6 (Wound Registered Nurse) said that he found R1's wound on 2/3/24. V6 said that the wound had eschar and some drainage but did not have an odor and was not painful. V6 said that he put in an order for a foam dressing to be applied and changed on Monday, Wednesday, and Friday until she saw the wound physician for further treatment. V5 (Wound Director) said that he was called to the room on 2/5/24 to look at the wound. V5 said that he took the dressing off and noticed an odor, so he applied Dakin's solution (antiseptic wound cleaner) and wanted the dressing changed daily using Dakin's until she saw the wound physician. On 2/14/24 at 2:38 PM, V6 said that he did not notify R1's physician of her new pressure ulcer. V6 stated, We do not call the doctor all the time if a resident develops a pressure ulcer. We can use our judgement until the resident is seen by the wound physician. We only call them if there is an issue like we think it is infected or something. R1's EMR does not document that R1's physician was notified when there was a change to R1's wound (odor) and no new orders were placed on R1's TAR on 2/5/24. Page 1 of 2 145923 145923 02/14/2024 Warren Barr North Shore 2773 Skokie Valley Road Highland Park, IL 60035

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few R1's Wound Evaluation and Management Summary dated 2/8/24 shows that the wound physician saw R1, and the pressure wound on her sacrum was classified as a stage 4 pressure ulcer measuring 3.6 cm x 4 cm x 1 cm. R1's dressing treatment plan was for Dakin's-soaked gauze wet to moist dressing daily. Under additional wound details it shows, Unavoidable and unpredictable wound secondary to decline in overall pt (patient) condition Pt has been sharply declining in all faculties including PO (by mouth) intake, mobility/activity, and mental acuity which no doubt instigated the wounds development Was found to have developed an open wound on her sacrum on Saturday; The wound was already fairly large and necrotic with odor, which appeared in only 1 day; Dakin's dressing was started immediately, and family was notified that day . R1's February 20245 TAR shows that the daily dressing change using Dakin's solution was not ordered until 2/10//24 (7 days after wound was identified). R1's TAR and Nursing Notes do not show that she had received any dressing changes using Dakin's solution or that it was done daily since the wound was first identified. R1's TAR shows that treatment of: cleanse with NS, pat dry, and apply bordered foam dressing to her sacrum wound was performed on 2/3, 2/5, 2/6, and 2/9/24. The facility's Skin Care Treatment Regimen Policy revised on 7/28/23 shows, Charge nurses must document in the nurse's notes and/or the Wound Report form any skin breakdown upon assessment and identification. Furthermore, topical skin treatment must be obtained from the patient's physician .TAR Nursing Documentation: Routine wound care completed by wound care nurse or designee Topical Treatment Protocol: Unless otherwise indicated by the attending physician stage 3 and 4 Cleaned wound Base: Ca Alginate, Hydrocolloid Gauze/gel daily, xeroform gauze. Necrotic areas: Santyl Ointment daily . 145923 Page 2 of 2