§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.
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Observations:
Based on a review of clinical records and incident reports, resident and staff interviews it was determined that the facility failed to consistently provide care and services, consistent with professional standards of practice, to prevent the development of pressure ulcers for one resident out of four sampled residents (Resident 110).
Findings:
According to the US Department of Health and Human Services, Agency for Healthcare Research & Quality, the pressure ulcer best practice bundle incorporates three critical components in preventing pressure ulcers: Comprehensive skin assessment, Standardized pressure ulcer risk assessment and care planning and implementation to address the areas of risk.
The American College of Physicians (ACP) is a national organization of internists, who specialize in the diagnosis, treatment, and care of adults. The largest medical-specialty organization and second-largest physician group in the United States) Clinical Practice Guidelines indicate that the treatment of pressure ulcers should involve multiple tactics aimed at alleviating the conditions contributing to ulcer development (i.e. support surfaces, repositioning and nutritional support); protecting the wound from contamination and creating and maintaining a clean wound environment; promoting tissue healing via local wound applications, debridement and wound cleansing; using adjunctive therapies; and considering possible surgical repair.
A review of Resident 110's clinical record revealed she was most recently admitted to the facility on August 22, 2023, with diagnoses including diabetes, muscle wasting, chronic kidney disease, and peripheral vascular disease (PVD).
Resident 110's care plan dated December 17, 2023, indicated that the resident was at risk for skin integrity breakdown due to diagnosis of diabetes, venous insufficiency, vitamin deficiency, bilateral lower extremity edema, with a history of diabetic foot ulcer of her right ankle. The stated goal is that she be free from pressure injuries through the next review, and identify risks, with a target date of April 25, 2024. Planned interventions were to elevate the resident's bilateral lower extremities and heels, on 2-3 pillows while at rest, apply moisturizing lotion in the morning and in the evening with care, moisturizer cream to bilateral feet daily, inspect skin daily with care and bathing, and report any changes, keep bed linen clean, dry, and free of wrinkles, keep skin clean and dry, maintain adequate nutrition and hydration. Encourage resident to frequently shift weight, initiated, February 2, 2024.
The resident's care plan noted actual impairment to skin integrity of the lateral foot, an intact blister, related to edema dated October 9, 2023.
A nurses note dated December 25, 2023, 11:20 AM, revealed that a blister like area was noted on the fifth toe of the resident's right foot. Minimal pain noted per resident, supervisor informed and in to assess area. Betadine was applied. Certified Registered Nurse Practitioner (CRNP) was consulted, will see the resident tomorrow. The entry noted that the resident had the same area in the past, and that nursing will continue to monitor.
A skin and wound note dated December 26, 2023, 4:11 PM revealed right lateral foot, stage 2, measuring 2 centimeter (cm) x 1 cm x 0 cm, blister (nonthermal), right foot. Recommendations were to cleanse the area with normal saline, apply skin prep to base of the wound, leave open to air, change daily. Preventative measure off loading of affected area, repositioning according to assessed needs, follow up in 1 week.
A nurses note dated December 27, 2023, 10:11 PM while providing wound care to resident's right foot, nursing noted edema to the resident's bilateral lower extremities. Nursing notified the CRNP, and a new order was received to increase the resident's Lasix 40 mg daily (a diuretic medication to remove excess fluid from the body), which had been decreased to 20 mg on December 15, 2023.
A nurses note dated January 2, 2024, 12:45 PM indicated that a Physical Therapy (PT) evaluation was ordered related to the new pressure injury to the resident's right foot. A "Multidisciplinary Therapy Screen" dated January 3, 2024, indicated that the resident was independent with transfers, bed mobility, and ability to move both lower extremities. Resident reported that she doesn't utilize shoes. The resident stated that while in bed, she lays on her left side with her right foot elevated. Physical Therapy intervention was not required secondary to the resident being independent.
A skin/wound note dated January 22, 2024, 12:09 PM, indicated that the area on the right lateral foot was resolved and treatment discontinued.
A review of a skin and wound note dated February 1, 2024, at 10:14 PM, indicated that the resident informed nursing that the area on her foot was hurting. Upon assessment, an intact blood blister noted to right lateral foot by 5th toe, "area is reoccurring." CRNP will be in to see resident. Betadine and dry dressing daily until seen by wound care. Resident aware. Resident rests her foot on stand of bedside table throughout the day while sitting and completing puzzles. Resident 110 is in chair for most of day. Resident has been educated several times by nursing that she needs to reposition that foot throughout the day to which she verbalizes understanding. Will continue to monitor site and encourage resident to reposition her foot while in chair. CRNP aware of above.
During interview with Resident 110 on February 7, 2024, at approximately 11:50 AM, the resident's feet were observed resting directly on the metal frame of her bedside table, which was positioned in front of her. The resident was wearing non-skid socks, with her right foot pressed against the bare metal of the bedside table frame. The resident stated that she spends many hours every day in her chair. She stated there are "only so many places" to put her feet, while sitting in a chair, and with the bedside table in front, it is a challenge not to have her feet above, below, or resting on the beside the frame. Resident 110 stated that staff is well aware that she does not wear shoes.
Interview with Employee 1, Physical Therapist Therapy Director, on February 7, 2024, at approximately 1:05PM, confirmed the above screen and that the resident was known to not wear shoes. She further indicated that if the resident was to wear shoes, this could most certainly contribute to a blister, along with the potential for skin damage if the resident wore only socks, and pressure was applied to the resident's feet against a metal frame.
The facility was aware of the resident's risk factors for skin breakdown and recurrent pressure sore to the resident's foot, along with the resident's habit of not wearing shoes. The facility failed to develop and implement individualized approaches to address this risk/contributing factor to prevent pressure sore development.
Interview with the Director of Nursing (DON) on February 7, 2024, at approximately 1:30 P.M., confirmed that the facility failed to demonstrate the implementation of timely and adequate measures necessary to prevent the development of a reoccurring right foot pressure area.
28 Pa. Code 211.12 (d)(3)(5) Nursing services.
| | Plan of Correction - To be completed: 03/13/2024
1. Resident 110's pressure ulcer has healed, and skin interventions are in place to prevent skin breakdown.
2. Current residents with pressure ulcers will be reviewed by therapy and nursing to review skin interventions are in place per the Braden Scale and/or resident habits to prevent skin breakdown.
3. All new admissions are seen and evaluated by Wound Care Solutions, CRNP during weekly wound rounds the first rounding after initial admission. An audit will be conducted of resident interventions in place for any resident with a braden score of 12 or less weekly x4. Education will be provided by the DON or designee to the licensed nurses on skin interventions to prevent breakdown per the Braden Scale and/or resident habits. Braden scales will be completed and reviewed for each resident on a quarterly basis to ensure skin interventions are in place.
4. A skin intervention audit will be completed on residents with pressure ulcers weekly x4 weeks to validate that skin interventions are in place per the Braden Scale and/or patient habits. Care plans will be updated. Results will be reviewed with the Quality Assurance Performance Committee.
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