Health inspection·December 21, 2021

F580 §483.10(g)(14) Notification of Changes (i) A facility must immediately inform the resident; consult with the resident’s physician; and notify, consistent with his or her authority, the resident representative(s) when there is— (A) An accident involving the resident which results in injury and has the potential for requiring physician intervention. (B) A significant change in the resident’s physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); (C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or (D) A decision to transfer or discharge the resident from the facility as specified in §483.15(c)(1)(ii). The Department received a complaint regarding multiple quality of care issues. On 10/4/2021, an unannounced investigation was conducted at the facility. The facility failed to ensure necessary care and services to prevent pressure ulcer ([PU] injuries to skin and underlying tissue resulting from prolonged pressure on the skin) development including, but not limited to, the following: 1. Failure to implement Resident 1’s plan of care, which included turning and repositioning the elbow every two hours. 2. Failure to report to the physician Resident 1’s right elbow wound changes, which worsened to a Stage IV (deep tissue injury with exposure of the muscles and/or bones) with drainage as required by the policy and procedure. 3. Failing to ensure the nursing staff completed and initialed the resident turn and reposition sheets every two hours as required by the care plan. As a result, Resident 1 developed a Stage IV pressure ulcer measuring three (3) centimeters ([cm] a unit of measurement) in length ([L] measurement of something from end to end) x 3 cm in width ([W] measurement of something from side to side) x 0.6 cm in depth (D) to the right elbow. The pressure ulcer wound had scant (small) sanguineous (blood tinged) drainage requiring several wound debridement (removal of damaged, dead or infected skin tissue from a wound) to promote wound healing which had the potential to result in further pressure ulcer development and secondary infections. Resident 1 was no longer in the facility. During a review of Resident 1's Admission Record (face sheet), the face sheet indicated the resident, a 90 year-old female, was initially admitted to the facility on 7/11/2018 and last re-admitted on 8/3/2021. Resident 1's diagnosis included diabetes mellitus (high sugar levels in the blood), difficulty walking, abnormal posture (slumped over), osteoarthritis (a joint disease characterized by pain, stiffness and swelling), dementia (a chronic or persistent disorder of memory loss with behavioral disturbance) and heart failure (the heart is unable to pump sufficiently to maintain blood flow to meet the body's needs). During a review of Resident 1’s Minimum Data Sets (MDS), a standardized resident assessment and care-screening tool, dated 12/3/2020 and 3/3/2021, the MDS indicated Resident 1 required extensive assistance of a one-person physical assist with bed mobility, toileting, personal hygiene, and a two-person assist with transfers. The MDS indicated Resident 1 was at risk for developing PU/PI and skin injuries and did not indicate Resident 1 had any ulcers, wounds, and skin problems. The MDS indicated Resident 1 had moisture associated skin damage ([MASD] injury to the skin due to prolong exposure to moisture), received skin treatments including pressure reducing device, turning, and repositioning program, application of nonsurgical dressings and applications of ointments and medications. During a review of Resident 1’s skin assessment, dated 8/29/2020 and timed at 4:51 p.m., the assessment indicated Resident 1 had discoloration on the right arm but did not have any pressure ulcer/pressure injury (PU/PI). During a review of Resident 1’s care plan, dated 11/8/2020 and titled, “Alteration in skin integrity pressure injury site right elbow, Stage I (intact or unopened skin with redness) related to right upper extremity contracture (tightening of muscles that prevents normal movement).” The staff’s interventions indicated for staff to provide treatment as ordered, perform wound assessment and documentation, turn, and reposition every two (2) hours, call the physician if the treatment was ineffective, position Resident 1 in bed in a way that the right elbow was not in contact with the bed by utilizing pillows as right arm is contracted. During a review of Resident 1’s Braden Scale (an assessment tool for predicting pressure sore risk) Pressure Sore Risk Assessment (PSRA), dated 12/3/2020, the PSRA indicated Resident 1 was assessed as having a score of 12. According to the Braden Scale Risk Assessment, a total score of 12 or less represented a high risk. During a review of Resident 1’s Nurse’s Progress Note (NPN), dated 12/16/2020 and timed at 1:34 p.m., the NPN indicated Resident 1’s right elbow ulcer was closed and had thin and fragile skin. During a review of Resident 1’s care plan, dated 1/2/2021 and titled, “Alteration in skin integrity pressure injury of right elbow abrasion.” The staff’s interventions indicated for the staff to provide treatment as ordered, perform wound assessment and documentation, turn, and reposition every two (2) hours, call the physician if the treatment was ineffective, provide good skin care and keep dry and clean. During a review of Resident 1’s NPN, dated 1/12/2021 and timed at 6:42 p.m., the NPN indicated Resident 1 received treatment for a re-opened right elbow abrasion. During a review of Resident 1’s recapitulated ([recap] a summary) physician’s orders, dated 1/26/2021, the physician’s orders indicated for a wound consult evaluation and treatment of the right elbow non-blanchable (skin lesions that do not fade when pressed) redness was ordered on 11/8/2020. During a review of Resident 1’s Weekly Wound Observation (WWO) form, dated 2/4/2021 and timed at 11:51 a.m., the WWO indicated Resident 1 had a re-opened right elbow abrasion (Stage I) that measured 3 cm x 2 cm, with no slough (shedding of the outer layer of skin), eschar (dead tissue that sheds or falls off from the skin) or granulation (the development of new skin tissue). The WWO indicated Resident 1’s physician was notified. During a review of Resident 1’s care plan, dated 2/4/2021 and titled, “Alteration in skin integrity pressure injury of right elbow re-opened abrasion.” The staff’s interventions indicated for staff to provide treatment as ordered, perform wound assessment and documentation, turn, and reposition every two (2) hours, call the physician if the treatment was ineffective, and provide good skin care and keep dry and clean. During a review of Resident 1’s WWO, dated 2/18/2021 and timed at 2:30 p.m., the WWO indicated Resident 1’s re-opened right elbow abrasion was assessed and measured at 1.8 cm x 0.8 cm with no slough, eschar and/or granulation. The WWO indicated Resident 1’s physician and family were notified. During a review of Resident 1’s NPN, dated 2/19/2021 and timed at 2:02 p.m., the NPN indicated Resident 1’s right elbow Stage I was reassessed. During a review of Resident 1’s records there was no documented evidence of an assessment conducted on 2/19/2021. During a review of Resident 1’s physician’s orders, dated 3/5/2021 and timed at 1:52 p.m., the physician’s orders indicated for Resident 1 to receive treatment to the right elbow, which included cleanse with normal saline (salt water), pat dry, xeroform (an oil- based gauze dressing that covers and protect oozing wounds) to the area, cover with foam dressing daily for 14 days. During a review of Resident 1’s WWO, dated 3/11/2021 and timed at 11:50 a.m., the WWO indicated Resident 1’s right elbow wound measured 1.9 cm x 0.5 cm with no slough, eschar, or granulation. The WWO indicated Resident 1’s right elbow was healing slowly. During a review of Resident 1’s NPN, dated 3/19/2021 and timed at 2:48 p.m., the NPN indicated Resident 1’s right elbow had light serosanguinous (discharge that contains both blood and serum [a clear yellow liquid]) drainage. The NPN did not indicate Resident 1’s physician was notified of the change of condition of the right elbow wound. During a review of Resident 1’s WWO, dated 4/2/2021 and timed at 1:30 p.m., the WWO indicated Resident 1’s right elbow was “unstageable (unable to measure)” and it was reclassified as a pressure injury that measured 3 cm x 2 cm x 0.3 cm with no slough, eschar, or granulation. The WWO indicated for the staff to provide offloading (to minimizing or removing weight to help prevent and heal ulcers) to Resident 1’s right elbow. During a review of Resident 1’s NPN, dated 4/2/2021 and timed at 11:47 p.m., the NPN indicated Resident 1 was being monitored and received treatment for a right elbow PI (pressure injury). During a review of Resident 1’s care plan, dated 4/2/2021 and titled, “Alteration in skin integrity pressure injury of unstageable right elbow.” The staff’s interventions indicated for staff to provide treatment as ordered, perform wound assessment and documentation, turn, and reposition every two (2) hours, call the physician if the treatment was ineffective, provide good skin care and keep dry and clean and wound consultant (a wound consultation for evaluation of pressure injuries). During a review of Resident 1’s new physician order, dated 4/15/2021 and timed at 2 p.m., the physician’s orders indicated for a wound consult evaluation of Resident 1’s right elbow. During a review of Resident 1’s WWO, dated 4/20/2021 and timed at 7:45 p.m., the WWO indicated Resident 1’s right elbow wound had worsened to a Stage IV pressure ulcer and measured 2.9 cm x 2.9 cm x 0.6 cm with 100% slough and a small amount of sanguineous (blood tinged) drainage and with no eschar or granulation. The WWO indicated Resident 1 was seen by the wound consultant physician. During a review of Resident 1’s Wound Consultant Note (WCN), dated 4/27/2021, the WCN indicated Resident 1 was assessed and indicated Resident 1’s right elbow wound had reopened and worsened significantly. The WCN indicated Resident 1’s right elbow PU measured 3 cm x 3 cm x 0.6 cm and was a Stage IV sacral wound, with 30% slough, 40% granulation, 30% necrotic (dead) tissue and had an odor. The WCN indicated Resident 1’s right elbow PU was debrided and the wound care consultant recommended aggressive offloading of Resident 1’s right elbow PU. During a telephone interview on 10/4/2021 at 10:09 a.m., Resident 1’s family member (FM 1) stated Resident 1 had a right elbow contracture since 2/2019 and in 7/2020 Resident 1 developed a small sore on her right elbow. FM 1 stated he and FM 2 were made aware of Resident 1’s right elbow pressure ulcer had progressed from a Stage I to a Stage IV during a meeting on 5/31/2021. During an interview on 10/5/2021 at 2:30 p.m., Treatment Nurse/Licensed Vocational Nurse 1 (TN/LVN 1) stated residents with a Stage I PI/PU are reported to the physician, a change of condition (COC) note is completed, the family/responsible party would be notified, a care plan initiated, daily wound documentation and weekly wound documentation would be completed. TN/LVN 1 stated if the resident’s skin was not improving then the staff would complete another COC note, notify the physician, and ask the physician for the resident to be seen weekly by the wound care specialist. During an interview on 10/15/2021 at 12:05 p.m., TN 2/LVN 3 was ask what should be done when a resident’s skin was blanchable and remained red, TN 2/LVN 3 stated she would notify the physician, monitor the resident’s skin, provide wound care treatments, and turn and reposition the resident every 2 hours. The TN 2/LVN 3 was asked how she would know when residents are being turned and repositioned every 2 hours, the TN 2/LVN 3 stated there is a turn and reposition sheet, the LVN must sign after the CNAs sign on each position. During an interview on 11/4/2021 at 4:32 p.m., TN 3/LVN 4 stated she covers for the TNs 1-2 days weekly and conduct resident wound care treatments. TN 3/LVN 4 stated offloading meant placing the resident’s extremities up in the air and when residents are lying in bed. TN 3/ LVN 4 stated offloading required the CNAs turning and repositioning every 2 hours and/or as needed to reduce pressure from the resident’s pressure sites. TN 3/ LVN 4 was asked how she ensured offloading residents with contractures, TN 3/ LVN 4 stated the facility used proper equipment such as a wedge pillow (a foam pillow that is higher in the front), hand-rolls, hand mittens and foot protectors. TN 3/ LVN 4 stated the CNAs must complete the turn and reposition sheet every 2 hours which the charge nurses sign to ensure offloading was conducted. TN 3/ LVN 4 was asked how she ensured the residents were being turned and repositioned every 2 hours, the TN 3/LVN 4 stated by looking at the residents, how the resident’s pillows were positioned and if the linens were tucked in very well. TN 3/ LVN 4 stated she would notify the wound care consultant/physician if the resident had a wound consult order resident and had a skin abrasion and/or opening of the skin. During a review on 11/4/2021 at 4:49 p.m., of the CNAs turn and reposition sheets located in the “West” nursing station, the sheets dated 11/4/2021 and timed at 8 a.m., 10 a.m., 12 p.m., and 2 p.m., there were a total of eight (8) residents without the CNA and/or the LVN initials to indicate the residents were positioned every 2 hours. Two of the eight reposition forms were blank without any staff signatures to indicate the residents were not being turned. During a concurrent interview and review of the “West” Nursing Station reposition sheets on 11/8/2021 at 10:45 a.m., the Director of Nursing (DON) confirmed there were no CNA and LVN initials for the eight (8) residents who required turning and repositioning every two hours on 11/1/2021 thru 11/7/2021. The DON stated the CNAs and licensed staff should have completed the reposition sheets. The DON stated the TN was responsible for notifying the wound consultant when Resident 1’s right elbow worsened or resulted in a pressure ulcer. The DON was asked did the licensed staff notify the wound consultant when Resident 1’s right elbow progressed from an open abrasion on 2/4/2021 to a Stage IV on 4/20/2021 since there had been an order for a wound consult since 11/8/2020. The DON stated the staff did not notify the wound consultant until 4/20/2021 and the staff should have because now Resident 1’s right elbow was a Stage IV pressure ulcer. During a telephone interview on 11/8/2021 at 12:47 p.m., TN 6/LVN 7 stated she has been performing wound care treatment off and on for a few months. TN 6/LVN 7 stated Resident 1 had an abrasion on her right elbow that re-opened, gradually went bad and was not healing well. TN 6/LVN 7 was asked what is done when the resident’s wounds were not healing, the TN 6/LVN 7 stated she would get the wound consultant involved to see the resident’s wounds. TN 6/LVN 7 was asked if she notified the wound consultant for Resident 1’s right elbow after her observation of the right elbow not healing, the TN 6/LVN 7 stated she did not notify the wound consultant for Resident 1 and should have. During a review of the facility’s revised policy and procedure (P/P), dated