Health inspection·May 18, 2021

F600 §483.12 Freedom from Abuse, Neglect, and Exploitation The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident’s medical symptoms.

F686 §483.25(b) Skin Integrity §483.25(b)(1) Pressure ulcers. Based on the comprehensive assessment of a resident, the facility must ensure that— (i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual’s clinical condition demonstrates that they were unavoidable; and (ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. On 2/23/2021 an unannounced visit was made to the facility to investigate a complaint about quality of care. The facility failed to ensure Resident 1 was free from neglect by not providing the necessary care and services to promote healing of pressure ulcers (injury to skin and underlying tissue due to prolonged pressure over a bony structure). The facility failed to: 1. Provide pressure ulcer treatments as ordered by the physician. 2. Monitor progress of the pressure sores, response, and effectiveness of treatment. 3. Notify the physician of lack of improvement of pressure sores. 4. Identify newly developed pressure ulcers. 2. Develop care plan to address each pressure ulcer. As a result, Resident 1 developed newly acquired pressure ulcers, the existing pressure ulcers worsened and resulted in developing osteomyelitis (bone infection). Resident 1 was placed at risk for serious complications including sepsis (a life-threatening complication of an infection. Sepsis occurs when chemicals released in the bloodstream to fight an infection trigger inflammation throughout the body. This can cause a cascade of changes that damage multiple organ systems, leading them to fail, sometimes even resulting in deaths). A review of Resident 1’s Admission Record indicated an admission dated 8/13/2020 with diagnoses including diabetes mellitus (is a disorder in which the body does not produce enough or respond normally to insulin, causing blood sugar [glucose] levels to be abnormally high), seizure (sudden, uncontrolled electrical disturbance in the brain) and protein-calorie malnutrition (deficiency in protein and calorie intake). A review of Resident 1's clinical record after admission on 8/13/2020 indicated there was no documented baseline skin assessment to determine the number and stage of pressure ulcers upon admission. A review of Resident 1's Braden Risk Assessment Report (a tool used to assess a resident's risk of developing a pressure ulcer) dated 8/14/2020 indicated a score of 14 or moderate risk. A review of Resident 1’s Minimum Data Set (MDS - standardized assessment and care-screening tool), dated 8/20/2020, indicated Resident 1 had severely impaired cognition (ability to think, understand and reason) and was totally dependent on staff with bed mobility, transfers, dressing, toilet use, and personal hygiene. Resident 1 was assessed at risk for developing pressure ulcers. A review of Resident 1's Physician's Orders dated 8/19/2020 indicated daily treatment for the following pressure sores: 1. Sacrum (tailbone) Stage 4 pressure ulcer (full thickness skin tissue loss extending into the muscle, tendon, ligament, cartilage [type of tissue that cushions bones and joints] or even bone); cleanse with Normal Saline (NS - solution used to clean the wound), pat dry, apply hydrogel (a wound treatment that provides moisture to the wound), cover with Opti foam (wound foam dressing) daily and PRN (as needed) if soiled for 21 days with a stop date 9/9/2020. 2. Left hip Deep Tissue Injury (DTI - injury to the soft tissue under the skin due to pressure and is usually over bony prominence); cleanse with NS, pat dry, apply xeroform (wound dressing) and opti foam daily for 21 days with a stop date 9/8/2020. 3. Right hip Stage 1 (superficial reddening of the skin); cleanse with NS, pat dry, apply zinc oxide (used to treat minor skin irritations) with stop date 9/1/2020. 4. Right ankle DTI; cleanse with NS, pat dry, apply zinc oxide (used to treat minor skin irritations) cream every shift for 14 days with a stop date of 9/8/2020. A review of Resident 1's Treatment Administration Record (TAR) for the month of 8/2020 indicated the above-mentioned treatments (sacrum, left hip DTI, right hip Stage 1, and right ankle DTI) were initiated on 8/20/2020 and had missing initials of the nurses, indicating treatments were not provided on multiple days. A review of Resident 1's Physician's Orders and TAR for the month of 11/2020, 12/2020, 1/2021, and 2/2021 indicated several pressure and diabetic ulcers (open sore or wound and is commonly located on the bottom of the foot) treatment with missing evidence the treatments were administrated daily as ordered. There were missing initials of the nurses, indicating treatments were not provided on multiple days. A review of Resident 1's clinical record from 10/2020 to 2/2021, indicated there was no documented evidence the licensed nurses performed assessment of each pressure ulcer to identify their initial presentation, their progress, response to treatment, their description (size, color, secretion, etc.) and if the physician was informed of each wound status. A review of Resident 1's care plan indicated no documented care plan addressing Resident 1's skin integrity and pressure ulcers from 8/13/2020 to 2/7/2021 for: 1. Right Hip Stage 1 2. Left foot lateral-distal unstageable (type of pressure ulcer that has full thickness tissue loss but is either covered with necrotic [death of cells in an organ or tissue due to injury] tissue or by an eschar [a dry, dark scab]) 3. Left foot lateral-proximal unstageable 4. Right lateral foot DTI 5. Left heel diabetic foot ulcer 6. Right buttock DTI A review of Resident 1's Physician's Orders dated 2/7/2021 indicated to transfer Resident 1 to General Acute Care Hospital 1 (GACH 1) due to general weakness. A record review of Resident 1's Transfer Record dated 2/7/2021 indicated the resident had the following five wounds prior to transfer to GACH 1: 1. Left hip diabetic ulcer 2. Right buttock diabetic ulcer 3. Sacral stage 4 pressure ulcer, 4. Right foot diabetic ulcer 5. Left foot diabetic ulcer A review of Resident 1's GACH 1’s Wound Consult Notes dated 2/9/2021, indicated the resident had the following skin wounds upon admission on 2/7/2021: 1. Right Shoulder DTI with a measurement of 3 centimeter (cm-unit of measure) by (x) 3 cm. 2. Left Shoulder Unstageable with a measurement of 3 cm x 3 cm. 3. Left Ear DTI with a measurement of 3 cm x 1 cm. 4. Left Medial Knee DTI with a measurement of 4 cm x 3 cm. 5. Left Medial Heel Unstageable with a measurement of 1 cm x 1 cm, covered with slough (necrotic tissue). 6. Left Buttock Unstageable with a measurement of 6 cm x 6 cm. 7. Right Hip Unstageable with a measurement of 8 cm x 4 cm, demarcating (separating) from the edges. 8. Left Hip Stage 1 with a measurement of 20 cm x 10 cm. 9. Sacrum/Coccyx Stage 4 with a measurement of 6 cm x 5 cm x 0.6 cm down to fascia (tissue that separates muscle and other internal organs). 10. Right Lateral Ankle Stage 4 with a measurement of 3 cm x 3 cm x 0.4 cm with fascia exposed. 11. Right Lateral Foot DTI x 3 sites with a measurement of 1.5 cm x 1.5 cm. 12. Left Lateral Ankle Stage 4 with a measurement of 3 cm x 3 cm x 0.4 cm down to fascia. 13. Left Medial Foot Lateral DTI with a measurement of 1 cm x 1 cm. 14. Right Medial Ankle Stage 4 with a measurement of 2 cm x 2 cm x 0.3 cm. 15. Right Heel Unstageable with a measurement of 3 cm x 2 cm. A review of Resident 1’s GACH 1 Physician's Notes dated 2/12/2021 indicated antibiotic medications were administered to treat bacteremia (the presence of bacteria in the blood) and osteomyelitis (infection in a bone) over the sacrum/coccyx Stage 4 pressure ulcer. On 3/31/2021 at 12:05 p.m., during an interview and concurrent record review of Resident 1's TAR and Physician’s Orders from 9/2020 to 2/2021 with the Assistant Director of Nursing (ADON), ADON confirmed there was no evidence the treatment were provided on the dates the treatment was left blank. ADON verified there was no plan of care developed for the right hip, left and right foot and right buttock. On 4/3/2021 at 11 a.m., during an interview, Resident 1’s attending physician (MD 1) stated Resident 1 should have received wound care treatment as ordered. MD 1 stated it was likely the resident had not been assessed and repositioned as needed. On 4/9/2021 at 6 p.m., during an interview and concurrent record review, ADON verified there was no baseline skin assessment upon Resident 1’s admission and there was no assessment of each individual wound and some wound assessments were not done weekly per policy. A review of the facility's policy titled "Prevention of Pressure Injuries," revised 4/2020, indicated Assess the resident on admission (within eight hours) for existing pressure injury risk factors. Repeat the risk assessment weekly and upon any changes in condition. Monitoring. Evaluate, report and document changes in the skin. Review the interventions and strategies for effectiveness on an ongoing basis. The policy further indicated that the facility should have a system/procedure to assure assessments are timely and appropriate and changes in condition are recognized, evaluated, reported to the practitioner, physician, and family, and addressed. Interventions and Preventative Measures: General. Routinely assess and document the condition of the resident's skin per Weekly Skin Integrity form for any signs and symptoms of irritation or breakdown. Report any signs of a developing pressure ulcer to the physician. The care process should include efforts to stabilize, reduce or remove underlying risk factors; to monitor the impact of the interventions; and to modify the interventions as appropriate. A review of the facility's policy titled "Pressure Ulcers/Skin Breakdown - Clinical Protocol," revised 4/2018, indicated the nurse shall describe and document/report the following: Full assessment of pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissue; current treatments, including support surfaces. The staff and practitioner will examine the skin of newly admitted residents for evidence of existing pressure ulcers or other skin conditions. The physician will assist the staff to identify the type (for example, arterial or stasis ulcer) and characteristics (presence of necrotic tissue, status of wound bed, etc.) of an ulcer. The physician will help identify and define any complications related to pressure ulcers. Cause Identification. The physician will clarify the status of relevant medical issues; for example, whether there is a soft tissue infection or just wound colonization (presence of a microorganism in the body that does no harm), whether the wound has necrotic tissue, and the impact of comorbid conditions (more than one disease or condition is present in the same person at the same time) on healing an existing wound. Treatment/Management. The physician will order pertinent wound treatments, including pressure reduction surfaces, wound cleansing and debridement approaches, dressings (occlusive, absorptive, etc.) and application of topical agents. The physician will help staff characterize the likelihood of wound healing. Monitoring. During resident visits, the physician will evaluate and document the progress of wound healing- especially for those with complicated, extensive, or poorly-healing wounds. The physician will guide the care plan as appropriate, especially when wounds are not healing as anticipated or new wounds develop despite existing interventions. Current approaches should be reviewed for whether they remain pertinent to the resident/patient's medical conditions, are affected by factors influencing wound development or healing, and the impact of specific treatment choices made by the resident/patient or a substitute decision-maker. A review of the facility's policy titled "Abuse and Neglect - Clinical Protocol," revised 3/2018, indicated "Neglect," meant "the failure of the facility, it's employees or services providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress.” The facility failed to ensure Residents 1 was free from neglect by not providing the necessary care and services to promote healing of pressure ulcers. The facility failed to: 1. Provide pressure ulcer treatments as ordered by the physician. 2. Monitor progress of the pressure sores, response, and effectiveness of treatment. 3. Notify the physician of lack of improvement of pressure sores. 4. Identify newly developed pressure ulcers. 2. Develop care plan to address each pressure ulcer. As a result, Resident 1 developed newly acquired pressure ulcers, the existing pressure ulcers worsened and resulted in developing osteomyelitis. Resident 1 was placed at risk for serious complications including sepsis. The above violations presented either an imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result to Resident 1.