Health inspection·July 2, 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 record review, interview and facility policy review, the facility failed to document treatments completed on two pressure ulcers for one resident (#111) of three residents reviewed. The facility census was 96. Residents Affected - Few Findings include: Review of the medical record for Resident #111, revealed an admission date of 09/29/20. Diagnoses included but were not limited to schizophrenia, other reduced mobility pressure ulcer of left buttock stage IV (Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling) and dependence on other enabling machines and devices. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 15 out of 15 which indicated cognitive intactness. The resident was assessed to require dependence on toilet hygiene, partial/moderate assistance with transfers and independent with bed mobility. The resident was also assessed to have two stage IV pressure ulcers on readmission/reentry with no refusal of care behaviors. Review of Resident #111's active care plans revealed a focus of an actual area of skin impairment related to stage IV pressure to left and right ischial with interventions including but not limited to: treatment order to left and right ischial changed per Nurse Practitioner and treatment as ordered. Review of physician's orders dated for 04/16/24 with a discontinued date of 05/06/24 for Resident #111 revealed two wound orders: cleanse wound to left ischium with normal saline, irrigate wound, pat dry, pack wound with collagen sheet, follow with packing and gauze and secure twice a day and as needed every shift for wound care and cleanse wound to right ischium with normal saline, irrigate wound, pat dry, pack wound with collagen sheet, follow with packing and gauze and secure twice a day and as needed every shift for wound care. Further review of this resident's physicians orders dated for 05/07/24 with a discontinuation date of 06/10/24 revealed two orders: Mupirocin external ointment 2 % apply to left ischium topically every shift for wound care cleanse wound to left ischium with normal saline (irrigate) pat dry, pack wound with Mupirocin covered gauze, cover with dressing, twice a day and as needed and Mupirocin external ointment 2 % apply to right ischium topically every shift for wound care cleanse wound to right ischium with normal saline (irrigate) pat dry, pack wound with Mupirocin covered gauze, cover with dressing, twice a day and as needed. Page 1 of 2 365435 365435 07/02/2024 Embassy of Logan 300 Arlington Avenue Logan, OH 43138

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Residents #111's Treatment Administration Record (TAR) for May 2024 revealed for both wound orders dated 04/16/24 had missed treatments for day shift for: 05/04/24, 05/05/24 and 05/07/24. Further review revealed for both wound orders dated 05/07/24 had missed treatments for day shift for: 05/23/24, 05/24/24, 05/28/24, and 05/031/24. Review of active physicians orders dated for 06/10/24 for Resident #111' revealed two wound orders: Mupirocin external ointment 2 % apply to left ischium topically every shift for wound care cleanse wound to left ischium with normal saline (irrigate) pat dry, drop 2-3 drops of Tetracyte into wound bed, pack wound with Mupirocin covered gauze, cover with dressing, twice a day and as needed and Mupirocin external ointment 2 % apply to right ischium topically every shift for wound care cleanse wound to right ischium with normal saline (irrigate) pat dry, drop 2-3 drops of Tetracyte into wound bed, pack wound with Mupirocin covered gauze, cover with dressing, twice a day and as needed. Resident #111's TAR for June 2024 revealed for both wound orders dated 05/07/24 had missed treatments for day shift for: 06/01/24, 06/07/24 and 06/10/24. Further review revealed for both wound orders dated 06/10/24 had missed treatments for day sift for: 06/11/24, 06/12/24, 06/14/24, 06/16/24, 06/17/24, 06/21/24, 06/23/24, and 06/30/24. On 07/02/24 at 9:45 A.M., Resident #111 refused to interview and refused to have his dressing change observed to his right and left ischium. Interview on 07/02/24 at 9:45 A.M. with the Director of Nursing (DON) verified Resident #111 had missed treatments for multiple orders for the left and right ischium for May and June 2024 on the TAR. Interview on 07/02/24 at 10:13 A.M. with Licensed Practical Nurse (LPN) verified Resident #111 had missed treatments for multiple orders for the left and right ischium for May and June 2024 on the TAR and stated, I am the nurse who takes care of him during the week most days and I religiously change it when he lets me. Also verified unable to document late entries for the missed treatments due to the resident does refuse as well and no form of confirmation for what days it was completed and what days he refused. Review of the facility policy titled Medication and Treatment Orders dated 03/01/2022 stated treatment orders .will be documented in PCC and on the TAR. This deficiency represents non-compliance investigated under Master Complaint Number OH00155246. 365435 Page 2 of 2