Health inspection·December 22, 2022

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 observations, interviews, and record reviews, the facility failed to ensure residents with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for one (Resident #36) of one resident reviewed for wound care, in that: Residents Affected - Few LVN A failed to complete the treatment for one wound at a time, to change gloves and perform hand hygiene appropriately, and to clean her scissors while providing wound care for Resident #36. These failures could place residents with wounds at an increased and unnecessary risk of cross contamination causing possible complications such as pain, worsening of existing wounds, and infections. Findings included: A review of Resident #36's admission Record dated 12/22/22 revealed a [AGE] year-old male re-admitted to the facility on [DATE]. Resident #36 had diagnoses of atherosclerotic heart disease of native coronary artery (plaque build-up in the coronary artery), chronic kidney disease stage 3, acute osteomyelitis (inflammation in bone caused by infection) right ankle and foot, stage 4 pressure ulcer of right heel, and unstageable pressure ulcer of left heel. A review of Resident #36's admission MDS dated [DATE] revealed his BIMS score was 15, which meant he had no cognitive impairment. The admission MDS reflected he required extensive assist of 2 plus staff for bed mobility, transfers between surfaces, dressing and toilet use. This document further revealed he had a stage 4 pressure ulcer of his right heel and an unstageable pressure ulcer of his left heel A review of Resident #36's care plan revised on 10/11/22 indicated problem, goals, and interventions: -Problem: The resident has unstageable pressure ulcer to right heel and a left heel stage II of the left heel r/t disease process coronary artery disease, acute kidney disease, anemia, and immobility. -Goal: The resident's pressure ulcer will show signs of healing and remain free of infection through review date of 02/15/22. -Interventions: Administer treatments as ordered and monitor effectiveness. Follow facility policies and procedures for the prevention/treatment of skin breakdown. Page 1 of 3 675238 675238 12/22/2022 Trinity Terrace 1600 Texas St Fort Worth, TX 76102

F 0686 Level of Harm - Minimal harm or potential for actual harm A review of Resident #36's Wound Evaluation dated 12/19/22 reflected, unstageable pressure ulcer of the left heel that measured 1.41 CM length X0.94 CM width. It also revealed the ulcer had a stable progress. The wound eval further revealed a Stage 4 pressure ulcer of his right heel that measured 3.75 length CM X 2.75 CM width and it had a wound bed of slough (necrotic tissue that needs to be removed) with a light amount of exudate (drainage). Residents Affected - Few A review of Resident #36's Medication Review Report reflected an order dated 12/13/22 for: Wound #1: Cleanse left heal wound with N/S, pat dry. Apply Silver Alginate dressing, and cover wound with bordered gauze dressing every day shift related to PRESSURE ULCER OF LEFT HEEL, UNSTAGEABLE (L89.620) AND as needed related to PRESSURE ULCER OF LEFT HEEL, UNSTAGEABLE (L89.620) If dressing becomes soiled or dislodged. A review of Resident #36's Medication Review Report reflected an order dated 12/13/22 for: Wound #2: Cleanse Right Heel wound with N/S, pat dry, Cover with Silver Alginate, ABD pad, wrap with Kerlix and secure with tape every day shift related to PRESSURE ULCER OF RIGHT HEEL, STAGE 4 (L89.614) AND as needed If dressing becomes soiled or dislodged. An observation on 12/22/22 at 11:25 AM revealed LVN A, after removing Resident #36's bilateral soft boots and placing them under his lower legs, she opened and placed a chuck (A disposable incontinent pad) under his feet. LVN A removed the island dressing from Resident #36's left heel which left the silver alginate dressing stuck to the wound bed. LVN A picked up her scissors and cut through the kerlix wrap on Resident #36's right foot, took it off with the ABD pad and placed them on the chuck under his feet. The silver alginate dressing remained stuck to the wound bed on his right heel as well. LVN A washed her hands, gloved, took a 4X4 gauze and NS bullet, wet the gauze and cleaned Resident #3's left heel wound, removing the silver alginate dressing. Without changing her gloves or performing hand hygiene, LVN A got another 4X4 gauze , wet it using a NS bullet, placed it over the right wound with silver alginate stuck to wound. LVN A Held it there for a few moments then held it against the silver alginate on his right heel wound bed, then worked the silver alginate off. LVN A used another 4X4 gauze , wet it with the NS and cleaned the right heel wound again. LVN A then changed her gloves and sanitized her hands, picked up the scissors, and without sanitizing them, opened the silver alginate dressing and cut it to the size of the left heel wound and stuck it into the wound bed then placed an island dressing over it. LVN A, without changing gloves and performing hand hygiene, picked up the silver alginate dressing and placed it into the right wound bed, put an ABD pad over it, then used a gauze roll to wrap Resident #36's foot, and taped it at the end. An interview on 12/22/22 at 12:05 PM with LVN A, after asking about doing the wounds together, said this was only her second time working with Resident #36, she was an agency nurse, did not do wounds very often and had never done them with state observing. When asked about the scissors she stated I realized as soon as I cut the silver alginate that I should have cleaned them first to prevent contaminating the wound, but it was already done so she had continued. An interview on 12/22/22 at 12:40 PM revealed the DON expected her staff to wash their hands, after cleaning the table, set up their supplies, wipe their scissors before starting and after cutting a bandage off, before cutting another clean dressing so there was no contamination. The DON stated if there were multiple wounds, they should do one wound at a time, to prevent cross contaminating the wounds. The DON stated she also expected her staff to wash their hands before they started, between dirty to clean tasks/areas, and if they were visibly soiled. After explaining what LVN A had done, the DON said she was going to send in one of the facility's nurses, but figured they needed to see 675238 Page 2 of 3 675238 12/22/2022 Trinity Terrace 1600 Texas St Fort Worth, TX 76102

F 0686 what the agency nurse knew. She said they were nurses so they should know the correct way to do things. Level of Harm - Minimal harm or potential for actual harm An interview on 12/22/22 at 1:40 PM the DON said they were starting check offs with all the nurses including the agency nurses on wound care and multiple wounds. She also said she had talked with LVN A who told her she knew she had done wrong, but she was nervous and did not know what to do. The DON said she told LVN A she could have started over on the wound care if nothing else. The DON said they do have checkoffs with the agency nurses when they come to work the first time, but they were going to redo them with all nurses now. Residents Affected - Few Review of the facility's Licensed Nurse Competency Checklist for LVN A dated 11/16/22 revealed: 8. Performed hand hygiene, put on gloves. 9. Removed dirty dressing and place in plastic bag. 10. Removed gloves and placed in plastic bag. 11. Performed hand hygiene. 12. Put on gloves. 13. Performed treatment . 15.Removed gloves and place in plastic bag. 16. Performed hand hygiene/Clean scissors or other equipment. Review of the facility policy and procedures for Skin-Wound Issues last revised 11/2015 revealed: .wash and dry your hands thoroughly .Put on gloves .Apply dressings as indicated .Clean and disinfect reusable supplies ( .scissor blades .) with alcohol or other disinfectant as indicated. 675238 Page 3 of 3