Health inspection·September 22, 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 medical record review, observation, resident interview, and staff interviews, the facility failed to ensure Resident #5's sacral pressure ulcer wound care was completed per the physician's order. This affected one (Resident #5) of three residents reviewed for pressure ulcers. The facility census was 99. Residents Affected - Few Findings include: Review of Resident #5's medical record revealed the resident was admitted on [DATE] with diagnoses including unspecified dislocation of the left hip with encounter for other orthopedic aftercare, muscle weakness and difficulty in walking. Review of Resident #5's admission assessment dated [DATE] revealed the resident's skin was intact (with the exception of a surgical hip wound the resident was admitted with). Review of Resident #5's comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition and required extensive two person assist for bed mobility and toilet use as well as extensive one person assist for dressing, personal hygiene, and bathing. Review of Resident #5's weekly skin check dated 08/02/23 revealed the resident had a recent left hip surgical site with a wound vac in place and was followed by the wound team. The resident did not have a pressure ulcer to the sacral area on this date. Review of Resident #5's initial wound track form dated 08/08/23 revealed the resident had a stage three sacral pressure wound (full-thickness skin loss with fat exposed) which measured 4.3 cm (centimeters) length by 7.6 cm width by 0.2 cm depth acquired 08/08/23. Current pressure prevention interventions included turning and repositioning the resident. New pressure prevention interventions included to elevate heel, low air-loss mattress and roho cushion to the wheelchair. Review of Resident #5's Wound Nurse Practitioner (NP) progress note dated 08/08/23 indicated the NP was consulted for evaluation of a pressure injury to the sacrum. Per the facility staff, the patient was non-compliant with skin checks, skin care and turning. Upon exam, the stage 3 pressure injury noted to the sacral region, contiguous with the bilateral buttocks, revealed a shallow, full thickness wound comprised primarily of red, moist tissue with some yellow, adherent tissue noted to the dermal layer as well. Review of Resident #5's skin integrity care plan dated 08/08/23 revealed the resident had a stage 3 pressure ulcer to the sacrum and interventions included to elevate the heels while in bed, a low air loss mattress with a perimeter overlay, moisture barrier after each incontinent episode, roho Page 1 of 2 365865 365865 09/22/2023 Main Street Care Center 500 Community Drive Avon Lake, OH 44012

F 0686 cushion to the wheelchair and turn and reposition in bed every two hours. Level of Harm - Minimal harm or potential for actual harm Review of Resident #5's physician orders revealed an order dated 08/08/23 to cleanse the sacrum with vashe wound wash and gauze, pat dry, apply triad to wound, top with alginate and cover with a bordered foam dressing daily and as needed. Residents Affected - Few Review of Resident #5's wound care progress note dated 08/23/23 revealed the resident had a stage 3 sacral pressure ulcer measuring 3.7 cm by 4.5 cm by 0.2 cm and the wound tissue color was 75% (percent) red and 25% yellow, adherent slough with a large amount of serosanguineous drainage. Review of Resident #5's Treatment Administration Records (TARS) from 08/08/23 to 09/20/23 revealed no evidence the sacral pressure ulcer wound care was completed on 08/10/23, 08/12/23, 08/29/23, 09/02/23, 09/15/23 and 09/16/23. Interview on 09/20/23 at 7:41 A.M. with Resident #5 indicated the facility staff did not change his sacral pressure dressing as ordered. Observation on 09/20/23 at 9:55 A.M. with Licensed Practical Nurse (LPN) #811, Nurse Practitioner (NP) #809 and LPN Wound Nurse #810 of Resident #5's incontinence care revealed the sacral pressure ulcer dressing was not in place at the time of the incontinence care. Interview on 09/20/23 at 10:05 A.M. with LPN Wound Nurse #810 confirmed Resident #5's TARS from 08/08/23 to 09/20/23 did not have evidence sacral pressure ulcer wound care was completed on 08/10/23, 08/12/23, 08/13/23, 08/29/23, 09/02/23, 09/15/23 and 09/16/23. A second interview on 09/20/23 at 10:11 A.M. with Resident #5 revealed he had a bowel movement in therapy at some point on 09/19/23 after breakfast and the State Tested Nursing Assistant (STNA) provided him incontinence care. Resident #5 confirmed the nursing staff did not replace the sacral pressure ulcer dressing after the STNA removed the dressing during the incontinence care. Review of an undated witness statement authored by Registered Nurse (RN) #802 revealed Resident #5's sacral dressing was applied on night shift (09/19/23) after he was placed in bed. He was changed a few times during the night. Interview on 09/20/23 at 10:15 A.M. with LPN Treatment Nurse #811 confirmed Resident #5's sacral pressure ulcer dressing was not in place when the staff were providing incontinence care. Interview on 09/21/23 at 1:18 P.M. with Regional Director of Operations #817 indicated the facility completed a Quality Assurance and Performance Improvement (QAPI) plan on 08/08/23 following identification of Resident #5's stage 3 sacral pressure ulcer wound with interventions including daily skin checks, audits and licensed staff education. Review of the Wound Prevention and Management Policy revised 10/22 indicated upon admission, all residents would have a comprehensive skin assessment to identify current skin breakdown and identify pressure ulcer risk factors. This deficiency represents non-compliance investigated under Complaint Number OH00145950. 365865 Page 2 of 2