Health inspection·May 23, 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 observation, record review and interview, the facility failed to ensure necessary treatment and services for pressure ulcers was provided according to physician's orders for Resident #29. This affected one resident (#29) of three residents reviewed for wounds. The facility census was 31. Residents Affected - Few Finding included: Review of the medical record revealed Resident #29 was admitted to the facility on [DATE] with diagnoses including Parkinson's disease, schizoaffective disorder, hypertension, COVID-19, repeated falls, cerebral infarction, and major depressive disorder. Review of the admission assessment dated [DATE] revealed Resident #29 was admitted with a red, blanchable left hip and a bony right trochanter. Review of the Braden scales dated 01/16/23, 02/07/23 and 05/03/23 revealed Resident #29 scored a seven indicating she was at high risk for pressure ulcer development. Review of the physician's orders revealed an order dated 01/16/23 for Resident #29 to wear heel boots as tolerated, 01/17/23 order to apply foam dressing to the left ischium every morning for skin integrity and 02/20/23 order for Resident #29 to be turned and repositioned every two hours and as needed every shift for preventative care. Review of the plan of care, revised 02/06/23 revealed Resident #29 was admitted to the facility with a pressure ulcer and Hospice care and had the potential for further skin breakdown because she required assist with mobility and was incontinent. Interventions included air mattress to the bed (03/22/23), notify the nurse of any skin abnormalities, wear heel boots as tolerated, weekly skin checks, apply barrier cream, float heels when in bed if resident allows, turn and reposition every two hours an as needed, and provide incontinence care after each episode. Review of the quarterly Minimum Data Set 3.0 assessment dated [DATE] revealed Resident #29 had severely impaired cognition, required extensive assistance from two staff members for bed mobility, transfers, dressing, toilet use and one staff member for eating and personal hygiene. Resident #29 was always incontinent of bladder and bowel, had a prognosis of less than six months and was at risk of pressure ulcer development. Review of the wound assessments dated 03/06/23 through 05/11/23 revealed Resident #29 was being monitored for skin breakdown to her coccyx/sacrum, left lower buttock/ischium, left hip/trochanter and right lateral foot. Resident #29 had end-stage disease. Page 1 of 3 366280 366280 05/23/2023 St Luke Lutheran Community-Portage Lakes 615 Latham LN Akron, OH 44319

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the nurse's note dated 03/08/23 at 1:18 P.M. revealed the nurse spoke with the social worker from hospice and asked her to ask the hospice nurse for an air mattress order due to Resident #29's left trochanter wound and the hospice social worker stated she would speak to the nurse and get it ordered for the facility. Review of the physician's orders dated 03/11/23 revealed Resident #29 had an order to apply skin prep and a silicone foam dressing to the left ischium every third day and as needed for skin integrity. Review of the nurse's note dated 03/13/23 at 2:45 P.M. revealed the nurse asked the hospice nurse on 3/10/23 for an air mattress for the resident and the hospice nurse stated to this nurse that hospice would not cover the cost of an air mattress, the resident did not meet the qualifications, and the resident had a gel overlay mattress. The Director of Nursing (DON) was notified. Review of the nurse's note dated 03/13/23 at 4:08 P.M. revealed the nurse called hospice and requested an air mattress for Resident #29. They stated they would have one delivered the next day. Review of the physician's orders dated 03/16/23 revealed Resident #29 had an order for an air mattress to the bed. Review of the physician's orders dated 03/27/23 revealed Resident #29 had an order to cleanse the sacrum, left buttock cheek and left hip with normal saline, apply calcium alginate with silver and Medi-honey, and cover with border foam dressing every day and as needed. Review of the physician's order dated 05/03/23 revealed Resident #29 had orders to cleanse the sacrum, left buttock cheek and left hip with normal saline, apply calcium alginate and Medi-honey, skin prep to the peri-wound and cover with border foam dressing every day and as needed and to cleanse the right foot planter with normal saline, apply collagen with silver and Medi honey, cover with abdominal dressing and wrap with kerlix every day and as needed. Review of the Treatment Administration Record (TAR), dated May 2023, revealed the orders dated 05/03/23 for treatments to the sacrum, left buttock cheek, left hip and right foot coincided with the physician orders dated 05/03/23. All of these orders were documented as being completed from 05/03/23 through 05/17/23 on the TAR. Observation on 05/18/23 at 1:15 P.M. with Hospice Aide (HA) #100 who was providing care to Resident #29 revealed Resident #29 had a dressing to her left hip, left buttock and right foot all dated 05/15/23. The dressing to the coccyx was not visible due to Resident #29 wearing a brief. Observation and record review on 05/18/23 at 1:20 P.M. with Agency Registered Nurse (ARN) #101 revealed Resident #29 had an order for her wound dressings to be changed daily and as needed. ARN #101 verified at this time the dressing to her left buttock, left hip and right foot were dated 05/15/23 and the dressing to the coccyx did not have a date on it as to when it had last been changed. On 05/18/23 at 2:05 P.M. an interview with Licensed Practical Nurse (LPN) #102 revealed she completed wound rounds with the Wound Nurse Practitioner (NP) every Thursday, however, Resident #29 was on hospice, so the wound NP would not see her. LPN #102 stated Resident #29's wound treatments had been ordered every three days, but the orders changed to daily on 05/03/23 per the daughter's request. LPN #102 stated there must have been a miscommunication because Resident #29's wound treatments were 366280 Page 2 of 3 366280 05/23/2023 St Luke Lutheran Community-Portage Lakes 615 Latham LN Akron, OH 44319

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few not getting done daily. LPN #102 stated she was trying to get to all residents with wounds, but she was only one person and the facility only had two staff nurses and the rest were agencies. LPN #102 verified the nurses should have seen that the order in the computer was changed to daily dressing changes and completed Resident #29's treatments daily. On 05/22/23 at 11:45 A.M. an interview with LPN #102 revealed she had asked the hospice for an air mattress, and it took them a week to give the facility an order for it. On 05/22/23 at 1:15 P.M. an interview with Family Member #801 revealed she had visited the facility on 05/02/23 and had concerns related to the resident's wound care. The family member indicated her mother's (Resident #29) room had a foul odor when she walked into the room and the wound dressings were dated 04/25/23. This deficiency represents non-compliance investigated under Complaint Number OH00142643. 366280 Page 3 of 3