Health inspection·June 7, 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 observation, interview and record review the facility failed to assess the skin underneath Resident #28's right lower extremity hinged brace resulting in an in-house acquired stage II pressure ulcer under the brace. This affected one resident (#28) of three residents reviewed for pressure ulcers. The facility census was 52. Residents Affected - Few Findings include: Review of the medical record for Resident #28 revealed an admission date of 04/23/24. Diagnoses included displaced comminuted fracture of the shaft of the right femur, chronic atrial fibrillation, and cerebral infarction. Review of the physician's order dated 04/26/24 revealed Resident #28 had an order for a right lower extremity hinged brace which was to remain intact and only to be removed for personal hygiene. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #28 had moderate cognitive impairment. Resident #28 required substantial/maximal assistance for eating, oral hygiene, upper body dressing, and showering/bathing. Resident #28 was dependent for toileting, lower body dressing, and putting on and taking off footwear. Resident #28 was frequently incontinent of urine and bowel. Resident #28 had no pressure ulcers on admission and was at risk of developing pressure ulcers. Review of the care plan for Resident #28 dated 05/08/24 revealed she was at risk for skin breakdown. Interventions included to assess skin weekly and turn and reposition every two hours. Review of the nursing progress note dated 05/18/24 for Resident #28 revealed an area was found on her right outer lower extremity under the hinged brace. The physician and her family were notified. Review of the skin incident/accident witness statement dated 05/18/24 authored by Licensed Practical Nurse (LPN) #530 revealed she was called to Resident #28's room by a state tested nurse aide (STNA) and observed the area to the right outer lower leg. Review of the skin incident/accident witness statement dated 05/18/24 by STNA #522 revealed she was doing care for Resident #28 when she complained of pain in her right lower leg. The STNA #522 got a mirror and looked inside her brace and found a new skin area and notified the nurse. There was no documented evidence that treatment orders were implemented until 05/20/24. Review of weekly skin assessment dated [DATE] revealed family was notified of the wound on Page 1 of 2 366191 366191 06/07/2024 Maplecrest Nursing and Hta 400 Sexton Street Struthers, OH 44471

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 05/18/24. The lateral right lower extremity was found to have a stage II pressure ulcer (partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough, may also present as an intact or open/ruptured serum filled blister) identified on 05/18/24. The wound bed was epithelial tissue, slough, and was moist. There was a scant amount of serosanguinous drainage with no odors. The wound measured 28 millimeters (mm) length by 6 mm width, by 1 mm depth. The surrounding skin was dry and intact erythematous. An order to clean with normal saline, apply optical AG and cover with a foam dressing. The comment section revealed it was from her hinged brace to her right lower extremity, per surgeon it may only be removed for hygiene purposes. A treatment order was put into place to assess skin every shift under the brace. Review of physician orders revealed on 05/20/24 orders for low air loss mattress to bed and check function every shift. Prosource (supplement) 30 milliliters (ml) by mouth twice a day for wound healing. Check placement of hinged brace to right lower extremity and assess skin integrity under the brace every shift. The resident was to have a protective boot to the left lower extremity at all times and a heel protector to the right lower extremity while in bed for skin integrity. Interview on 06/07/24 at 8:15 A.M. with Resident #28 confirmed she had a wound on her right lower extremity that was caused by the brace she must wear. She reported the staff was caring for it and it is healing. Interview on 06/07/24 at 8:49 A.M. with Wound Care Registered Nurse (RN) #548 confirmed that Resident #28 was admitted with a hinged brace to her right lower extremity. She reported staff informed her that they were checking underneath the brace but there was no documented evidence of it until an area was identified on 05/18/24. She confirmed when she returned to work on 05/20/24 she assessed Resident #28's wound with the wound care team. They put treatments in place including for the staff to check residents' skin under the brace every shift. She also completed an in-service with the staff to educate them on the new changes for when a resident is admitted with a brace. RN #548 also confirmed that residents were assessed with no new findings. Review of the in-service completed on 05/20/24 revealed eleven nurses signed the sign in sheet. Observation on 06/07/24 at 9:44 A.M. of wound care for Resident #28 with STNA #530 and Wound Care RN #548 revealed the area was clean and the edges were dry. There was moderate amount of serosanguineous drainage with no odor. Good hand hygiene and resident privacy was maintained during the observation. This deficiency represents noncompliance investigated under Complaint Number OH00154076. 366191 Page 2 of 2