Health inspection·October 24, 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 clinical record review and staff interview it was determined that [NAME] Skilled Nursing and Rehabilitation Center failed to ensure that residents were assessed and monitored to prevent pressure ulcers for one of one residents reviewed (Resident R72). Residents Affected - Few Findings include: Review of Resident R72's clinical record revealed resident was admitted on [DATE]. Further review of clinical record revealed Resident 72's diagnoses include; Diabetes Mellitus (failure of the body to produce insulin to enable sugar to pass from the blood stream to cells for nourishment), Vascular Dementia (lack of blood carrying oxygen and nutrient to a part of the brain, causing problems with reasoning, planning, judgment, and memory); Malnutrition; and Abnormalities of gait. Review of Resident R72's clinical record revealed most recent Braden Scale (assessment of risk of developing pressure ulcers) dated June 15, 2023 which indicated resident was considered High Risk to develop pressure ulcer/wound. Review of Resident R72's clinical record revealed a care plan addressing skin integrity. Further review of care plan revealed interventions initiated on April 17, 2023 of barrier cream to peri area (skin between the genitals and the anus) and buttocks; encourage fluids; encourage repositioning as needed; and use assistative devices as needed. Additional review of Resident R72's skin integrity care plan revealed an intervention added on October 23, 2023 of Administer treatment per physician orders. Review of Resident R72's clinical record including Tasks documentation for showers failed to reveal documented showers on designated shower days of Tuesday/Thursdays for previous 30 days. Further review of Resident R72's clinical record revealed most recent showers recorded for September 26 and September 29, 2023. Review of Resident R72's September 2023 and October 2023 Medication Administration Record (MAR)/Treatment Administration Record (TAR) revealed body audits occurred on September 5, 2023; September 12, September 19, September 26, October 3, and October 10, 2023. Further review of Resident R72's clinical record including September 2023 and October 2023 MAR/TAR failed to reveal documetnation of the administration of barrier cream to resident's peri area/buttocks to prevent pressure wounds. Page 1 of 2 395685 395685 10/24/2023 Wallingford Skilled Nursing and Rehabilitation Cen 115 South Providence Road Wallingford, PA 19086

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident R72's clinical record revealed a General Progress Note dated October 23, 2023 (02:25 a.m.) indicating; Pt.[patient] alert and responsive; +[positive] confusion noted; during inc.[incontinence] care it was noted that stage 2 pressure ulcer on sacral area shape of butterfly both R&L[right&left] buttocks; measuring 1cm[centimeter]X .5cm R buttoks and 1/2 cm X 1/2 cm L buttocks; N.O. [new order] for cleanse wound with wound cleanser and apply med honey and foam dressing and to change BID [twice a day]; rep.[repeat] freq.[frequently] and monitor for placement; DON [Director of Nursing] made aware; family message left and will recall in AM; MD [medical doctor] made aware. Further review of Resident R72's progress notes revealed a General Progress note dated October 23, 2023 (13:18 or 1:18 p.m.) which indicated, MD assessed and wrote new order for medihoney to b/l buttocks wound daily with foam dressing. New order for Roho cushion (cushion that distributes pressure off bony prominence of buttocks), will be ordered. [Family] was here and notified of new orders. Review of Resident R72's clinical record revealed a Medical Practitioner's Note dated October 23, 2023 (14:13 aka 1:13 p.m) indicated [Resident] [DOB] HPI [History Physical Information]: Pt seen for follow up for wound on buttocks. St III (Stage 3 - wound that progressed to the third layer of skin into the fatty tissue) with small amount of slough (form of necrotic tissue, contains ingredients such as fibrin, leukocytes, dead cells, microbes, and proteinaceous materials) noted to multiple small areas ~1cm. Plan medihoney and ROHO cushion for WC (wheelchair). Review of Resident R72's clinical record failed to reveal skin assessments documenting appearance or condition of skin during observations times such as showers or body audits. The above information was relayed to the Nursing Home Administrator and Director of Nursing on October 23, 2023 at approximately 10:15 p.m. The facility failed to monitor and assess Resident R72's skin to prevent pressure wound. 28 Pa Code 395685 Page 2 of 2