Health inspection·January 10, 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, observation, staff interview and policy review, the facility failed to initiate treatment on a pressure ulcer present upon a resident readmission. This affected one (#77) out of three residents reviewed for wound care. The facility census was 102. Residents Affected - Few Findings include: Record review revealed Resident #77 was admitted to the facility on [DATE] and was recently readmitted on [DATE]. Diagnoses include acute and subacute infective endocarditis, bacteremia, anxiety, morbid obesity, type two diabetes, non-displaced fracture of the fifth metatarsal bone, right foot, and obstructive sleep apnea. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 10/15/23 revealed Resident #77 had a pressure ulcer/injury, a scar over bony prominence, or a non-removable dressing/device - one stage three pressure area present. Review of Resident #77's care plan initiated on 01/06/24 revealed a care focus for set-up assistance with eating with intervention of staff assistance of set-up. A care focus for substantial assistance on oral hygiene and dressing with intervention of staff assistance of substantial assistance. A care focus for total assistance for toileting, showering and personal hygiene with intervention of staff assistance of dependent care. A care focus of stage three pressure area present on admission with an intervention of pressure reduction/reducing mattress. Review of Resident #77's physician orders revealed an order dated 01/06/24 for weekly skin assessment to be completed. Documentation to be completed on weekly skin assessment every day shift every Saturday for skin assessment skin health, and order dated 01/06/24 for skin prep to right heel every day shift for deep tissue injury (DTI), and an order dated 01/06/24 for Prevlon boots while in bed every day and night shift for DTI remove every shift. Review of Resident #77's progress notes revealed a re-entry date of 01/06/24 which revealed an open area to the residents coccyx, a deep tissue injury (DTI) to right heel and yeast in folds. Review of Resident #77's nursing admission evaluation dated 01/06/24 revealed pressure area to coccyx, no measurements documented. Review revealed documentation indicated a treatment order is in place for each skin area noted - answer yes. Further review of Resident #77's medical record revealed no physician order and no entry on the treatment administration record (TAR) for treatment to the residents coccyx. There was no further Page 1 of 2 365514 365514 01/10/2024 Allen View Healthcare Center 2615 Derr Road Springfield, OH 45503

F 0686 documented evidence of a treatment being applied to Resident #77's coccyx. Level of Harm - Minimal harm or potential for actual harm Observation on 01/10/24 at 8:49 A.M. revealed an open area to coccyx of Resident #77 during incontinence care completed by State Tested Nursing Assistant (STNA) #126. Resident #77's coccyx wound was elongated in size with depth noted in center of wound, pink in color with scant amount of serosanguineous drainage present. Observations revealed there was no dressing in place to Resident #77's coccyx wound. Residents Affected - Few Observation on 01/10/24 at 3:12 P.M. with Registered Nurse (RN) #12 revealed Resident #77 with an open area to the coccyx. Resident #77's coccyx wound was cleansed with normal saline wound cleanser, wound measured with measurements of 9.0 centimeters (cm) x 1.0 cm x 0.5 cm. Silver alginate applied to wound. Interview on 01/10/24 at 10:55 A.M. with Licensed Practical Nurse (LPN) #72 revealed this is the first time she has worked with Resident #77 since re-admission. Interview with LPN #72 also confirmed there was not an order for treatment to Resident #77 coccyx wound. Interview on 01/10/24 at 1:31 P.M. with RN #12 revealed the nurse on the floor at the time of an admission or re-admission would do a head-to-toe assessment, remove all dressing to look at every part of the body. The nurse should measure all wounds. Contact the physician for treatment orders at the time of admission or re-admission. Interview also revealed the wound physician and the wound nurse see all new admissions and re-admissions on weekly wound rounds. A head-to-toe assessment is completed again, measurements of all areas of concern and treatments will be initiated if they need to be. Interview also revealed current orders are reviewed by the wound physician and wound nurse weekly. Interview also confirmed there was not a treatment order in place for Resident #77's coccyx wound since re-admission on [DATE]. Interview on 01/10/24 at 1:58 P.M. with Nurse Practitioner (NP) #09 revealed he was not contacted on 01/06/24 when Resident #77 was readmitted regarding the wound on the coccyx or to implement a treatment. NP#09 also stated that the expectation would be to initiate the treatment that was previously in place prior to resident going out to the hospital or to initiate a new treatment based on new orders received from the hospital. Interview 01/10/24 at 3:51 P.M. with Director of Nursing (DON) revealed she was not aware of Resident #77 not having a treatment initiated on re-admission to the coccyx wound. Interview with the DON also confirmed a treatment should be initiated on all wounds. Interview on 01/10/24 at 4:19 P.M. with LPN #19 confirmed she was the nurse on duty when Resident #77 re-admitted on [DATE] and that she did not initiate an order a treatment to the coccyx wound. Review of Monitoring A Wound policy, undated revealed it is the facility policy to re-evaluate with change in clinical condition, prior to transfers to the hospital and upon return from the hospital and to implement wound treatments as ordered. This deficiency represents non-compliance investigated under Complaint Number OH00149699. 365514 Page 2 of 2