Health inspection·March 21, 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 a review of the facility's policy, clinical records review, and staff interview, it was determined that the facility failed to comprehensively assess a wound identified upon admission and failed to place a treatment order timely for one of three residents reviewed (Resident CL1). Residents Affected - Few Findings include: Review of the facility's policy titled Wound Care Management, undated revealed that all residents are assessed on admission, quarterly, and with a change of condition. Documentation will include the length, width, and depth of the wound and the appearance of the wound. Review of Resident CL1's clinical records revealed Resident CL1 was admitted to the facility on [DATE], with a diagnosis of Sepsis - (The body's extreme reaction to an infection, without prompt treatment can lead to organ failure, tissue damage, and death). Review of Resident CL1's clinical record including Nursing admission Screening/History dated February 20, 2024, at 5:30 p.m., revealed a resident with a wound on the sacrum (tail bone) with a measurement of 5.0 x 3.0 x 3.0 cm. The wound assessment revealed no information regarding the wound's appearance which includes wound bed, drainage, etc. The same form revealed Wound treatment or required to cleanse the wound with normal saline, apply Medihoney- (A dressing that aids and supports debridement and a moist wound healing environment in acute and chronic wounds and burns), and cover with a dry dressing. Review of Resident CL1's clinical record failed to reveal that the Medihoney wound treatment was put in as an order and therefore was not transcribed into the resident's Treatment Administration Record. Interview with licensed nurse Employee E3 was conducted on March 21, 2024. Employee E3 reported that the nursing supervisor was responsible for assessing wounds identified on admission. Employee E3 confirmed that the initial wound assessment was not done comprehensively. Employee E3 reported that an agency nurse worked that day and was unable to say the reason why the wound treatment on Resident CL1's sacrum was not ordered. Review of Resident CL1's clinical record including wound consult dated February 21, 2024, revealed that Resident CL1's wound was assessed and evaluated by the wound physician. The sacral wound was identified as Unstageable (Obscured full-thickness skin and tissue loss) necrosis, measuring 3.0 x 2.5 x 0.5 cm, 50% thick adherent necrotic tissue, with light serous drainage. The treatment plan is as follows: Leptospermum Honey is applied once daily covered with bordered dressing daily for 30 days. Page 1 of 2 395166 395166 03/21/2024 Aventura at Pembrooke 1130 West Chester Pike West Chester, PA 19380

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident CL1's clinical record revealed Leptospermum wound treatment for Resident CL1's unstageable necrosis wound to sacrum was not put in as an order until February 23, 2024, two days after the wound treatment recommendation was made by the wound physician. Interview with Employee E3 on March 21, 2024, revealed that she/he was with the wound physician during the consultation on February 21, 2024, but the physician did not mention a wound treatment order. Employee E3 reported that the consultation form which had the information of the resident's wound assessment/evaluation and recommended treatment plan was not received by the facility until February 23, 2024. Review of Resident CL1's clinical record revealed Resident Cl1's unstageable necrosis sacral wound treatment order was not implemented until February 23, 2024, three days after the wound was identified on admission day. The above information was discussed with the Nursing Home Administrator and Director of Nursing on March 21, 2024. The facility failed to ensure Resident CL1's unstageable sacral wound was comprehensively assessed upon admission and treatment order was put in place timely. 28 Pa. Code 211.5(f) Clinical records 28 Pa code 211.10 (c) Resident care policies 28 Pa. 211.12(c)(d)(1)(3)(5) Nursing services 395166 Page 2 of 2