|§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.
Based on observations, interviews with staff, and review of clinical records and facility documentation, it was determined that the facility failed to insure that interventions to reduce the risk of pressure ulcers were performed by staff for two of three residents reviewed (Residents R1 and R2).
Review of the clinical record for Resident R1 revealed a Minimum Data Set (MDS - assessment of need), dated January 7, 2019, that indicated this resident had diagnoses that included heart failure, anemia, right hand contracture, and acute kidney failure. This MDS also indicated that the resident was diagnosed with dementia and had severely impaired cognition as well as impairment of an upper extremity. This MDS further indicated that this resident required extensive assistance to change positions while lying in bed
Continued review of Resident R1's record revealed an assessment, dated September 21, 2018, that indicated that this resident was at risk for developing a pressure ulcer. Continued review revealed a subsequent assessment, dated December 19, 2018, indicating that she was at very high risk for developing a pressure ulcer. Further review revealed a care plan, regarding this risk for pressure ulcers, that contained interventions that included encouraging and assisting the resident to reposition.
While on-site, Resident R1 was observed to be in bed in a supine position (up back, face upward), during all observations of this resident throughout the day, including 10:00 a.m., 12:00 noon, 1:00 p.m., and 2:45 p.m.
Review of the clinical record for Resident R2 revealed a MDS, dated February 15, 2019, that indicated this resident had diagnoses that included cerebral vascular accident CVA-stroke, brain hemorrhage), hemiplegia (paralysis/weakness to one side of the body), muscle weakness, and acute kidney failure). This MDS also indicated that this resident had impaired range of motion to both her upper and lower extremities and that she required extensive assistance to change positions while in bed. It further indicated that her cognition was severely impaired.
Review of the care plan regarding pressure ulcer risk for Resident R2 revealed an intervention , dated January 7, 2019, to encourage the resident to reposition. Continued review of the clinical record revealed an assessment, dated January 29, 2019, that indicated R2's ability to change positions was very limited and that she was at risk for developing a pressure ulcers.
While on-site, Resident R2 was observed to be in bed in a supine position (up back, face upward), during all observations of this resident throughout the day, including 10:00 a.m., 12:00 noon, 1:00 p.m., and 2:45 p.m.
In an interview with the Administrator, at approximately 3:15 p.m. on February 21, 2019, it was confirmed that two residents, Residents R1 and R2, who were both assessed to be at risk for the development of pressure ulcers, had been observed to be in the same position throughout the day.
28 Pa Code 211.5(f) Clinical records Previously cited 9/28/18
28 Pa Code 211.12(c)(d)(1)(2)(5) Nursing services Previously cited 9/28/18
| ||Plan of Correction - To be completed: 03/26/2019|
1. R1 and R2 were re-evaluated for turning and repositioning and patient centered care plan updated.
2. Current residents and new admissions have the potential to be effected by this deficient practice. Utilizing the Skin Quality Assurance and Performance Improvement tool patients at risk for skin breakdown will be evaluated to ensure turning and position is in place as appropriate.
3. Nursing staff will be educated on the skin practice guideline. Residents will be turned and positioned as per their patient centered plan of care.
4. Utilizing Nursing Services Quality Assurance and Performance Improvement tool Additional Observation #1 seven (7) patients will be audited weekly time 4 weeks to ensure patient centered plan of care is being followed with results reported to QAA for further recommendation.