Health inspection·December 7, 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 observation, interview and record review, the facility failed to ensure a resident received care, consistent with professional standards of practice, to prevent pressure ulcers and did not develop pressure ulcers unless the individual's clinical condition demonstrated they were unavoidable for 1 of 4 residents (Resident #1) reviewed for pressure ulcers. Residents Affected - Few The facility failed to ensure Resident #1's off-loading boot, which was used to prevent skin breakdown, was placed on the resident. This failure could place residents at risk for the development of pressure injuries. Findings included: Record review of Resident #1's face sheet, dated 12/07/2023, reflected the resident was a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included unspecified psychosis (experiencing symptoms of schizophrenia or other psychotic symptoms), acute respiratory disease (affects the lungs, bronchus and respiration), blindness in right eye, pressure induced deep tissue damage on left heal (affects subcutaneous tissue under intact skin), hypothyroidism (underactive thyroid), lack of coordination, and cognitive deficit disorder. Record review of Resident #1's initial MDS, dated [DATE], reflected a BIMS score of 4, which indicated severe cognitive impairment. Resident #1 required one-person assist / supervision for transfers and bed mobility, was at risk for pressure ulcers, had an unhealed pressure ulcer, and required a pressure reducing device for the bed. Record review of Resident #1's comprehensive care plan, dated 10/20/2023, revealed Problem: skin concerns as evidenced by DTI (Deep Tissue Injury) to heel. Goal: area will heal without complications over the next 90 days. Approach: heel protector on left foot when resident in bed. Record review of wound care notes dated 11/29/2023 and signed by the DON, reflected a closed pressure injury on the left heel, 2 cm by 3 cm noting an off-loading required. Wound care notes dated 12/6/2023, signed by the DON, reflected a new of shiny tissue, 2 cm by 2 cm pressure injury on the left heel and an off-loading boot required. An observation and interview on 12/07/2023 at 9:39 AM with Resident #1 revealed he was in bed. His off-loading boot was placed on the dresser beside his bed. A sign above Resident #1's bed stated, Please put boot on left foot at all times while in bed. Resident #1 stated he had a wound on his heel but denied any pain. When the off-loading boot, on the dresser, was pointed out to him, he said he Page 1 of 2 675270 675270 12/07/2023 Avir at Kennedale 413 E Mansfield Cardinal Kennedale, TX 76060

F 0686 did not know what the boot was for. Level of Harm - Minimal harm or potential for actual harm In an interview on 12/07/2023 at 9:56 AM, LVN A stated Resident #1 should have an off-loading boot on his left foot any time he was in bed. She said Resident #1 had a deep tissue wound on his left heel and the boot was to prevent skin breakdown. She stated she did not know Resident #1 was back in bed and thought he was at therapy. She said she did not know why the boot was not placed on his foot when he was put back in bed because there was a sign above his bed as a reminder to all staff. She stated the boot may have fallen off but doubted it would fall off and onto the dresser. Residents Affected - Few In an interview on 12/07/2023 at 10:01 AM, the Physical Therapist Assistant said she had been working with Resident #1 in the therapy gym and he told her he was tired and wanted to return to his bed. She said she returned Resident #1 to his bed but did not put the off-loading boot on his foot. She said she would normally tell the CNA or nurse that she had put Resident #1 back in bed but did not tell them today. She said she did not know why she did not think to put the boot on the resident or tell the nursing staff she returned him to his bed. She stated Resident #1 required the off-loading boot placed on his left foot any time he was in bed to prevent any skin breakdown. In an interview on 12/07/2023 at 11:50 AM, the DON said she did the treatments for all residents in the facility. She stated Resident #1 was admitted with a deep tissue injury on his left heel. She said he required an off-loading boot whenever he was in bed to prevent any skin breakdown. She said all staff were responsible to ensure this was done and she placed a sign above Resident #1's bed as a reminder for them. She said Resident #1 did take the boot off and they would find it on the floor but doubted he placed it on the dresser. She said she verbally educated staff on placing the off-loading boot but did not have a written in-service. She said she included therapy staff in any in-servicing she did, and the Therapy Supervisor also trained therapy staff. In an interview on 12/07/2023 at 12:40 PM, the Therapy Supervisor said the Physical Therapy Assistant told her she placed Resident #1 in bed but did not put on the off-loading boot or let the nursing staff know she put him in bed. She said Resident #1 should always have the off-loading boot on when in bed. She said not placing it on him put him at risk of skin breakdown and injury. In an interview on 12/07/2023 at 1:30 PM, the Administrator said she expected nursing staff to follow the care plan and ensure Resident #1's off-loading boot was in place when in bed. She said the boot was required to minimize pressure on Resident #1's heel and prevent skin breakdown. Record review of the facility's Skin-Preventative Guideline for Resident At Risk for Pressure Injury policy, dated December 2016, reflected, .A care plan will be developed that specified the interventions that will be taken for all pressure injuries. Pressure relief: consider pressure reducing devised for bed .Avoid friction, consider protective devises .use heel protective devises 675270 Page 2 of 2