Health inspection·February 29, 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 medical record review, staff interviews, and policy review, the facility failed to complete an assessment and implement a treatment for a newly developed pressure ulcer. This affected one (#43) out of three residents reviewed for pressure ulcers. The facility census was 65. Residents Affected - Few Findings included: Review of the medical record Resident #43 revealed an admission date of 09/01/16 with medical diagnoses of chronic obstructive pulmonary disease, chronic respiratory failure, peripheral vascular disease, and hypertension. Review of the medical record for Resident #43 revealed an annual Minimum Data Set (MDS), dated [DATE], which indicated Resident #43 was cognitively intact and required substantial/maximum staff assistance for bed mobility, bathing, transfers, and toileting. The MDS indicated Resident #43 was always incontinence of bladder and frequently incontinent of bowel. The MDS indicated Resident #43 did not have any pressure ulcers. Review of the medical record for Resident #43 revealed a nurse's note dated 02/15/24 at 5:50 P.M., written by Registered Nurse (RN) #217 which stated the nurse observed small pressure sore to the residents buttocks. The note continued to state the State Tested Nursing Assistant (STNA) informed her the area was present last week but had opened since then. The note stated the area was cleaned, ointment was applied, and the Assistance Director of Nursing (ADON) was notified. Further review of the medical record revealed a nurse's note, dated 02/16/24 at 11:40 A.M. which stated the nurse assessed the open area to resident's sacrum which measured 1.1 centimeters (cm) by 1.4 cm by 0.1 cm. The note stated the wound bed was dark red in the center and pink toward the outer edges and no drainage or odor was noted. The note continued to state the Physician Assistant, the wound Nurse Practitioner (NP), resident's power of attorney, and the dietician were notified. Review of the medical record for Resident #43 revealed a physician order dated 02/16/24 to cleanse sacrum with wound cleanser, pat dry, apply medi-honey to wound bed, cover with bordered gauze and to change daily and as needed. The medical record did not contain documentation to support a treatment to the sacrum was ordered prior to 02/16/24. Review of the medical record for Resident #43 revealed weekly skin assessments dated 02/05/24 and 02/12/24 which stated Resident #43 had no skin issues. The weekly skin assessment dated [DATE] stated Resident #43 had a small pressure sore to buttocks. Further review of the medical record revealed a pressure skin grid assessment dated [DATE] which stated Resident #43 was noted to have a Stage II pressure ulcer to the sacrum area on 02/15/24. The wound measured 1.1 cm by 1.4 cm by 0.1 cm. The Page 1 of 2 365601 365601 02/29/2024 Alpine Nursing and Rehabilitation Center 164 Office Park Drive Xenia, OH 45385

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few medical record for Resident #43 revealed a pressure skin grid assessment, dated 02/27/24, which indicated the Stage II pressure ulcer to Resident #43's sacrum was healing and measured 1.0 cm by 1.5 cm by 0.1 cm. Review of the medical record for Resident #43 revealed wound NP note, dated 02/20/24 which stated Resident #43 was evaluated for Stage II pressure ulcer to sacrum which was found on 02/16/24. The note indicated the wound measured 1.8 cm by 1.8 cm by 0.1 cm and was debrided during the evaluation. Review of the wound NP note, dated 02/27/24, stated the Stage II pressure ulcer to the sacrum had improved and measured 1 cm by 1.5 cm by 0.1 cm. Interview on 02/29/24 at 12:48 P.M. with RN #217 confirmed she was the nurse who took care of Resident #43 when the pressure ulcer to the sacrum was found on 02/15/24. RN #217 stated STNA #204 informed her the pressure ulcer was present the week before but was not open at that time. RN #217 stated she notified the Assistant Director of Nursing (ADON) #233 of the area to the sacrum for further assessment. RN #217 stated ADON #233 completed the pressure skin grid and notified physician for treatment orders. Interview on 02/29/24 at 2:09 P.M. with STNA #204 confirmed she informed RN #217 that the pressure ulcer to Resident #43's sacrum was present a week prior to 02/15/24. STNA #204 stated she notified Licensed Practical Nurse (LPN) #211 on 02/09/24 that Resident #43 had a small area to the sacrum. STNA #204 stated she was not aware if LPN #217 assessed the area or notified the physician for treatment orders. Interview on 02/29/24 at 2:25 P.M. with LPN #217 confirmed he was notified by STNA #204 that Resident #43 had an area on her sacrum. LPN #217 stated he assessed the area to Resident #43's sacrum and the area was red, was not open, and was not blanchable. LPN #217 stated he applied barrier cream and a bordered gauze and informed STNA #204 to notify the ADON the next day of the area to Resident #43's sacrum. LPN #217 confirmed he did not measure the area or notify the physician of the area for treatment orders. Review of the facility policy titled, Wound Care, revised November 2018, stated wounds would be monitored for location, size (measure length, width, and depth), undermining, tunneling, exudates, necrotic tissue, and the presence or absence of granulation tissue and epithelialization. The policy also stated to notify the physician upon discovery of new skin area and when delay in healing is noted and to obtain physician orders for treatment to begin at the time of discovery. This deficiency represents non-compliance investigated under Complaint Number OH00150850. 365601 Page 2 of 2