Health inspection·August 2, 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 interviews and medical record review, the facility failed to implement orders for a pressure ulcer treatment affecting one resident (#10) of three residents reviewed. The facility census was 68. Residents Affected - Few THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Findings include: The deficient practice was corrected on 06/22/24 when the facility implemented the following corrective actions: o Staff education was completed on 05/23/24 regarding the initiation and proper transcription of new orders. o Licensed Practical Nurse (LPN) #444 was counseled on 05/23/24 regarding the error. o An initial audit was conducted on 05/23/24 to verify all pressure ulcer orders were accurate. o Additional audits were performed from 05/26/24 to 06/22/24. Review of the medical record for Resident #10, revealed an admission date of 01/24/24. Diagnoses included but were not limited to spastic quadriplegic cerebral palsy, acute and chronic respiratory failure with hypoxia, unspecified mood disorder, and dependence on a respirator (ventilator) status. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 13 out of 15 indicating cognitive intactness. The resident was assessed to require total dependence on all aspects of care. Review of the active care plan for Resident #10 revealed an alteration in skin integrity as evidenced by pressure ulcer present at the left gluteal fold with interventions including but not limited to body check weekly and as needed, provide treatment per physician orders and to assess condition of skin/dressing. Review of Resident #10's record revealed a skin grid pressure discovered on 04/17/24 and was a stage 3 (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not Page 1 of 2 366374 366374 08/02/2024 Trueman Pointe Care Center 4660 Trueman Blvd Hilliard, OH 43026

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling) pressure ulcer to the left gluteal fold that measured 3.5 centimeters (cm) X 7 cm X. 1 cm. Review of the Wound Nurse Practitioner (NP) visit note dated 04/17/24 for Resident #10 revealed a new pressure wound; stage 3 pressure ulcer to the left gluteal fold that measured 3.5 centimeters (cm) X 7 cm X. 1 cm. Patient plan and order to apply a foam dressing to insulate, pad and protect, to be changed daily was noted. Review of Resident #10's physician orders revealed no dressing change order placed for the left gluteal fold stage 3 pressure ulcer until 04/23/24 and no order to evaluate and assess the pressure area dressing until 04/24/24. Review of Resident #10's Treatment Administration Record and progress notes revealed no documentation of a left gluteal fold stage 3 pressure ulcer dressing change daily as ordered by the Wound NP from 04/17/24 through 04/22/24. Interview on 07/31/24 at 1:24 P.M. with Licensed Practical Nurse (LPN) #444 revealed she is the nurse who does the wounds at the facility. Verified that when the Wound NP ordered a dressing change for the left gluteal fold on 04/17/24 the order was not placed into Resident #10's chart and no order for a dressing change was entered until 04/23/24, but she did complete the dressing changes even though there are no documentation of them being completed in the residents chart. The facility was unable to produce a policy on wound care for pressure ulcers. This deficiency represents non-compliance investigated under Master Complaint Number OH00155689 and Complaint Number OH00155383. 366374 Page 2 of 2