Health inspection·September 11, 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 interview and record review, the facility failed to ensure residents with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote wound healing, prevent infection and prevent new pressure ulcers from developing for one (Resident #1) of four residents reviewed for pressure injuries. Residents Affected - Some The facility failed to ensure all wound care treatments were completed and documented during the month of August 2024 for Resident #1. This deficient practice could place residents at risk of improper wound management and deterioration in existing pressure injuries. Findings included: Review of Resident #1's face sheet revealed a male who was admitted on [DATE], discharged on 09/09/24, and his own RP. Review of Resident #1's medical diagnoses revealed he had diagnoses including cognitive communication deficit, type 2 diabetes mellitus without complications, bed confinement status, unspecified disorder of the skin and subcutaneous tissue, sepsis unspecified organism (a serious condition in which the body responds improperly to an infection). Review of Resident #1's comprehensive MDS assessment dated [DATE], revealed Resident #1 had an 11 BIMS score, which indicated he had moderate cognitive impairment. Resident #1 also was at risk of developing pressure ulcers/injuries and had one unhealed Stage 2 pressure ulcer. Resident #1 required substantial/maximal assistance with bed mobility. Review of Resident #1's care plan, dated 07/12/24, revealed the following care areas: *Resident #1 was being treated for pressure ulcers. An intervention indicated LVNs and RNs were required to implement included treatments as ordered. *Resident #1 also had the potential for skin integrity and was at high risk for pressure ulcers. An intervention indicated staff were required to implement included providing skin care per facility guidelines and PRN. Review of Resident #1's order summary report revealed Resident #1 had a verbal order started on 08/12/24 to have staff conduct a dressing change to his coccyx area with Aquacel or Wound dressing Page 1 of 2 455670 455670 09/11/2024 Ridgecrest Retirement and Healthcare Community 1900 W State Hwy 6 Waco, TX 76712

F 0686 Silver biq two times a day. Level of Harm - Minimal harm or potential for actual harm Review of Resident #1's treatment administration record for August 2024 revealed staff were required to complete a dressing change to Resident #1's coccyx area with Aquacel or Wound dressing silver biq two times a day starting on 08/12/24 at 8:00 p.m. and ending on 08/27/24 at 11:28 a.m. There were no documented entries from 08/12/24 at 8:00 p.m. through 08/14/24 at 8:00 p.m. Additionally, there were no documented entries for 8:00 p.m. on 08/15/24, 08/17/24 through 08/22/24. Moreover, there were no documented entries for 08/20/24 at 8:00 a.m. Residents Affected - Some Review of Resident #1's progress notes from 08/12/24 through 08/26/24 revealed there was no documentation that indicated the order for wound care was followed . Review of Resident #1's progress note dated 08/27/24 at 12:25 p.m. written by (staff ID) indicated, Dressing change to coccyx area with Aquacel or Wound dressing Silver biq two times a day order changed per wound doctor. During an interview on 09/11/24 at 9:00 a.m., the DON stated LVNs and RNs documented wound care performed in residents' electronic health records. The DON stated LVNs and RNs performed wound care on residents according to orders. During an interview on 09/11/24 at 9:44 a.m., LVN A stated she cleaned residents' wounds and applied dressings according to residents' orders. LVN A stated she documented in residents' Treatment Administration Records when she completed providing wound care according to orders. During an interview on 09/11/24 at 10:23 a.m., RN B stated he received training on performing wound care. RN B stated he cleaned residents' wounds and applied ointments according to residents' orders. RN B stated he documented in residents' Treatment Administration Records when he completed providing wound care according to orders. Attempted to contact the WCD on 09/11/24 at 11:31 a.m. and at 12:59 p.m. A voicemail and call back number were left on both attempts. The WCD did not return the calls. Attempted to contact the WCND o 09/11/24 at 11:33 a.m. A voicemail and call back number were left. The WCND did not return the call. Review of the facility's Wound Care policy and procedure, undated, revealed staff were required to, .11. Apply treatments as indicated per MD order. Staff were also required to record the following information in residents' medical record, 1. The date and time the wound care was given. 6. The signature and title of the person recording the data. 455670 Page 2 of 2