Health inspection·January 19, 2024

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, resident and staff interview, review of the facility policy, and review of the guidelines from the National Pressure Ulcer Advisory Panel (NPUAP), the facility failed to implement a comprehensive and individualized pressure ulcer prevention program for Resident #25 to prevent the development of an unstageable (full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar) pressure ulcer. The facility also failed to accurately assess the wound as a facility acquired pressure ulcer. Residents Affected - Few Actual Harm occurred on 11/27/23 when Resident #25, who was at risk for pressure ulcers and required staff assistance for bed mobility and incontinence care was found to have an unstageable pressure ulcer to the sacrum without evidence of adequate interventions to prevent the development or timely identify the pressure ulcer prior to it being unstageable. This affected one resident (#25) of three residents reviewed for pressure ulcers. The facility census was 75. Findings include: Review of the medical record revealed Resident #25 was admitted on [DATE] with diagnoses including a fracture to the left femur, type II diabetes mellitus, spinal stenosis, and intellectual disabilities. Review of the hospital paperwork dated 11/22/23 revealed Resident #25 did not have skin breakdown upon discharge from the hospital. Review of the plan of care dated 11/22/23 revealed Resident #25 was at risk for impaired skin integrity related to the resident being confined to bed or chair most of the time, diabetes, impaired cognition, incontinence of bowel and bladder, pain, and required staff to assist with repositioning. Interventions included assisting Resident #25 with turning and repositioning as needed and completing a skin inspection every seven to ten days and as needed. On 11/29/23, a new intervention of an air mattress was added to the plan of care. Review of the admission note dated 11/22/23 at 4:45 P.M. revealed Resident #25 required two-persons assist for transfers and one-person assist for bed mobility. No skin impairments were observed. The Braden Scale used to determine the risk level for the development of pressure ulcers revealed Resident #25 was able to respond meaningfully to pressure-related discomfort, was rarely moist, was chairfast, had very limited ability to change and control body position, had adequate food intake, had no apparent problem with friction or shearing as evidenced by Resident #25 being able to move in bed/chair independently and had sufficient muscle strength to lift up completely during movement and maintained good position in bed/chair at all times. A Braden Scale assessment, revealed Resident #25 was Page 1 of 3 366095 366095 01/19/2024 Glenwood Care and Rehabilitation 836 West 34th Street NW Canton, OH 44709

F 0686 at low risk for the development of pressure ulcers. Level of Harm - Actual harm Review of the bath sheet dated 11/24/23 revealed Resident #25 was given a bed bath and no skin concerns were noted. Residents Affected - Few Review of an admission functional abilities and goals note, dated 11/27/23 revealed Resident #25 required substantial/maximal assistance for toileting hygiene, from lying to sitting on side of bed, and from sitting to standing. Resident #25 was dependent for chair/bed-to-chair and toilet transfer. Review of the nursing note dated 11/27/23 at 5:29 P.M. revealed a State Tested Nursing Assistant (STNA) notified the nurse that Resident #25 had a discolored and scabby area to the buttocks. The area was pink with dark discoloration and was dry. A Braden Scale assessment, dated 11/27/23 at 5:31 P.M. revealed Resident #25 was able to respond meaningfully to pressure-related discomfort, was occasionally moist, was chairfast, had very limited ability to change and control body position, had adequate food intake, and had a potential problem with friction or shearing as evidenced by Resident #25 moved feebly or required minimum assistance with skin probably sliding at some extent against the sheets/chair/devices. Resident #25 was at low risk for the development of a pressure ulcer. Review of the facility's wound evaluation dated 11/27/23 at 6:00 P.M. revealed Resident #25 had an unstageable pressure ulcer to sacrum that measured 8.2 centimeter (cm) long and 11.4 cm wide. The depth was not able to be determined due to slough (yellow/white necrotic tissue) and eschar (necrotic tissue) tissue being present. The wound was documented as a new wound and community acquired (present on admission). A new treatment was ordered. Review of the Medicare five-day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #25 was cognitively intact. Resident #25 was frequently incontinent of bowel and bladder and had one unstageable pressure ulcer present upon admission. Resident #25 required substantial/maximal assistance for toileting hygiene, lying to sitting, and sitting to standing. Resident #25 was dependent for toilet transfer. Review of the wound physician note dated 11/29/23 at 11:43 A.M. revealed Resident #25 was recently admitted from the hospital for therapy. Resident #25 had an unstageable pressure ulcer to left upper buttock which was present upon admission. The wound measured 3.7 cm long and 2.7 cm wide. The depth was undetermined due to the wound base having 40 percent slough tissue. The wound was debrided (damaged tissue removed) to reduce bacterial load and promote healing. A treatment of Triad (zinc oxide-based hydrophilic paste that adheres to moist wound beds and protects periwound skin) paste to be applied thickly was noted. Interview on 01/17/24 at 7:25 A.M. with Assistant Director of Nursing (ADON) #135 revealed the ADON was the facility wound nurse. ADON #135 verified the area to Resident #25's left buttock was considered present on admission because the wound developed within seven days of the resident's admission. ADON #135 verified the wound to Resident #25's left buttock/sacrum area was discovered five days after Resident #25 had been admitted . An additional interview on 01/17/24 at 10:29 A.M. with ADON #135 revealed Resident #25 had multiple comorbidities which made Resident #25 at risk for pressure ulcers. The ADON stated a skin check was completed upon admission and then weekly. ADON #135 verified the pressure ulcer was not present on 366095 Page 2 of 3 366095 01/19/2024 Glenwood Care and Rehabilitation 836 West 34th Street NW Canton, OH 44709

F 0686 admission and should have been documented as facility acquired pressure ulcer. Level of Harm - Actual harm Interview on 01/17/24 at 11:06 A.M. with Resident #25 revealed when the resident was first admitted , she laid on her back in bed most of the time due to pain from staples in her left leg. Resident #25 stated she was incontinent of urine frequently, but staff would only provide incontinence care every two hours. Residents Affected - Few Observation on 01/17/24 at 11:47 A.M. of dressing change for Resident #25 revealed a pink blanchable area to Resident #25's left inner buttock. Wound Nurse Practitioner #500 indicated the pressure ulcer area had healed but preventative treatment would continue. Interview on 01/19/24 at 8:08 A.M. with Therapy Manager #200 revealed at the time of admission (on 11/22/23) Resident #25 required maximum (staff) assist for all activities of daily living except for eating. Review of the facility's policy titled Pressure Ulcers/Skin Breakdown-Clinical Protocol, revised April 2018, revealed the staff and practitioner would examine the skin of newly admitted residents for evidence of existing pressure ulcers or other skin conditions. The nursing staff and practitioner would assess and document an individual's significant risk factors for developing pressure ulcers: for example, immobility, recent weight loss, and a history of pressure ulcer(s). Review of the NPUAP guidelines dated 2014 pages 70-71 at (https://npiap.com/general/custom.asp page=2014 Guidelines) revealed facilities should educate health professionals on how to undertake a comprehensive skin assessment that includes the techniques for identifying blanching response, localized heat, edema, and induration. Further review of the guidelines revealed ongoing assessment of the skin was necessary in order to detect early signs of pressure damage. Visual assessment for erythema (redness of the skin) was the first component of every skin inspection. Skin redness and tissue edema resulting from capillary occlusion was a response to pressure, especially over bony prominence. Staff should conduct a head-to-toe assessment with particular focus on skin overlying bony prominence's including the sacrum, ischial tuberosity, greater trochanters and heels and each time the patient was repositioned was an opportunity to conduct a brief skin assessment. This deficiency represents non-compliance investigated under Complaint Number OH00149774. 366095 Page 3 of 3