Health inspection·December 5, 2023

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 review of the medical record, staff interview, and policy review, the facility failed to ensure an admission skin assessment was completed, and failed to ensure wound treatments were entered into the electronic medical record and completed per physician orders. This affected one (Resident #79) of three residents reviewed for pressure ulcers. The facility census was 78. Residents Affected - Few Findings include: Review of the medical record for Resident #79 revealed an admission date of 09/23/23 and a discharge date of 10/15/23. Diagnoses included sepsis, encephalitis and encephalomyelitis, enterocolitis due to clostridium difficile, acute kidney failure, type two diabetes mellitus, chronic systolic heart failure, chronic kidney disease stage three, atrial fibrillation, and atherosclerosis of coronary artery bypass graft. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #79 had intact cognition. The resident required the extensive assistance of two staff for bed mobility, transfers, and toileting. The resident had an unstageable pressure ulcer present on admission. The resident was at risk for skin breakdown. Review of hospital documentation dated 09/21/23 revealed Resident #79 had an unstageable pressure ulcer to the sacrum measuring 6.2 centimeters (cm) in length, 7.5 cm in width with a depth of 0.1 cm. Review of the admission physician orders revealed an order to apply Triad hydrophilic wound dressing paste daily and as needed to the sacral wound. Review of the admission assessment for skin dated 09/23/23 revealed Resident #79 had abnormal findings for the sacrum. There was no description of the wound and no wound staging. Review of a weekly wound note dated 09/25/23 at 3:00 P.M. revealed Resident #79 was admitted with a unstageable pressure ulcer to the coccyx. The wound measured six cm in length, five cm in width, with an undetermined depth. The wound base was not visible with 100% slough/necrosis present with a moderate amount of thin tan colored drainage. Review of a physician order dated 09/25/23 at 3:00 P.M. revealed a new order to cleanse the coccyx wound with normal saline, pat dry, apply foam dressing, change daily and as needed. Review of the Nurse Practitioner (NP) wound progress note dated 09/25/23 revealed Resident #79 was Page 1 of 3 365535 365535 12/05/2023 Three Meadows Post Acute 10540 Fremont Pike Rd Perrysburg, OH 43551

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few admitted from the hospital on [DATE] with an unstageable pressure injury of the coccyx. The resident was on a turning schedule and had a low air loss mattress in place. The NP noted honey gel and dry dressing was being utilized. The wound measured six cm in length, five cm in width and unable to determine depth. There was no undermining or tunneling, no odor and the periwound was normal. The wound bed was 100% soft yellow slough with light to moderate serosanguinous drainage. The NP ordered to cleanse the injury with normal saline, apply medical honey and dry dressing daily and as needed. Review of the NP wound progress note dated 10/05/23 revealed the wound status was improved. The wound measured six cm in length by four cm in width with an undetermined depth. The wound was 100% slough with light to moderate serosanguinous drainage. There was no undermining, no tunneling, no odor and the periwound was normal. The NP noted to cleanse injury with normal saline, apply medical grade honey and dry dressing daily and as needed. Review of the NP wound progress note dated 10/12/23 revealed the wound status was improved. The wound measured 5.5 cm in length by 4.5 cm in width, with an undetermined depth. The wound bed was 50% slough and 50% granulation tissue with light to moderate serosanguinous drainage. There was no tunneling, no undermining and no odor. The periwound was normal. The NP debrided the wound and post debridement measurement remained unchanged. Post debridement appearance was 75% red granulation tissue and 25% yellow adherent nonviable tissue. The NP noted to cleanse the injury with normal saline, apply medical honey and dry dressing daily and as needed. Review of the Treatment Administration Record (TAR) from 09/25/23 through 10/14/23 revealed the wound was cleansed with normal saline, patted dry, and a foam dressing was applied. There were no documentation treatments were completed on 10/01/23, 10/03/23 and 10/10/23. Further review of the TAR revealed the wound treatment ordered by the NP on 09/25/23 (cleanse the injury with normal saline, apply medical honey and dry dressing daily and as needed) was never entered as a treatment order and therefore was not completed from 09/28/23 through 10/14/23. Interview on 12/04/23 at 9:55 A.M. Unit Manager Licensed Practical Nurse (LPN) #113 verified no wound assessment was completed until 09/25/23 (two days after admission). LPN #113 revealed the nurses should measure the wound upon admission. Further interview on 12/04/23 at 11:01 A.M. LPN #113 verified there were no documented treatments on 10/01/23, 10/03/23 and 10/10/23. LPN #113 also verified the incorrect treatment was completed from 09/28/23 through 10/14/23. LPN #113 revealed she used the medihoney on the wound but never entered the correct order in the electronic medical record. Interview on 12/05/23 at 10:15 A.M. Registered Nurse (RN) #118 revealed she used medihoney for a treatment on the Resident #79's coccyx wound. Interview on 12/05/23 at 11:59 A.M. Nurse Practitioner (NP) #120 revealed the resident's wound had improved. NP #120 revealed staff were likely using the medihoney as something worked to soften the slough in order for her to debride the wound. NP #120 revealed the resident received the medihoney treatment after the three times she had assessed the wound. NP #120 revealed medihoney would not work fast but the wound was cleaning up nicely. Review of the policy Skin Care Management, last revised 06/08/22 revealed residents with identified skin breakdown would have a documented skin assessment weekly. There were no guidelines for documentation of a skin assessment upon admission. Further review of the policy revealed wound treatments would be completed as ordered. 365535 Page 2 of 3 365535 12/05/2023 Three Meadows Post Acute 10540 Fremont Pike Rd Perrysburg, OH 43551

F 0686 This deficiency is an example of non-compliance investigated under Complaint Number OH00148231. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 365535 Page 3 of 3