§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 clinical record review, it was determined that the facility failed to provide appropriate interventions for the prevention of pressure ulcers and failed to timely identify a pressure ulcer resulting in actual harm to Resident CL5, who developed an unstageable pressure ulcer to the sacrum for one of 11 residents reviewed (Resident CL5).
Findings include:
Review of Resident CL5's clinical record revealed the resident was admitted to the facility on August 13, 2019 after sustaining a fall and a subsequent right femur fracture which required surgical repair.
Review of Resident CL5's Admission Minimum Data Set (MDS - periodic assessment of resident needs) dated August 20, 2019 revealed Resident CL5 had a Brief Interview for Mental Status Score of 8 indicating moderately impaired cognition, was frequently incontinent of bowel and bladder, and required extensive assistance from two staff members to reposition in bed. Further review of Resident CL5's Admission MDS also revealed the resident was at risk for developing pressure ulcers.
Review of Resident CL5's Physical Therapy Evaluation and Plan of Treatment dated August 13, 2019 identified the resident as needing moderate assistance for repositioning in bed.
Review of Resident CL5's care plan dated August 13, 2019 identified the resident as at risk for skin breakdown related to immobility with interventions including keep skin clean and dry, provide a pressure reducing mattress/air mattress when available and check the function every shift, and provide a well balanced diet. There were no interventions in place on the resident's risk for impaired skin breakdown addressing the resident's immobility and need for assistance with repositioning.
Review of Resident CL5's August 2019 Treatment Administration Record (TAR) revealed staff were documenting applying barrier cream to the resident's buttocks every shift starting on August 13, 2019.
Review of Resident CL5's admission assessment from August 13, 2019 identified the only skin concern as the resident's surgical incision to the right hip.
Review of Resident CL5's weekly skin assessment from August 20, 2019 identified no new skin concerns.
Review of Resident CL5's progress notes revealed a note dated August 26, 2019 which revealed Resident CL5 was now "noted with unstageable sacral wound measuring 3cm [(centimeters)] x 2.5cm x 0.1 cm with 100% slough [(separation of dead tissue from living tissue, yellow, tan, gray, green or brown)] noted at wound base. No drainage or odor noted. No complaint of pain at wound site. [Physician] and family aware. New orders noted. Air mattress to bed when available. Cleanse wound with [normal saline] apply santyl [(debriding agent)] and cover with dry dressing [daily], consult with wound care team, dietary consult." The resident's care plan dated August 13, 2019 indicated providing an air mattress when available, however 13 days later, on August 26, there was no air mattress in place and new orders for an air mattress were written on August 26, 2019.
Further review of Resident CL5's care plan revealed that the resident's plan of care for risk for impaired skin integrity was updated on August 26, 2019, the same day the sacral wound was discovered, with the intervention to encourage the resident to be out of bed during different intervals during the day and to encourage the resident to turn and reposition self every 2 hours. Prior to discovery of the sacral wound no interventions for repositioning were in place, despite Physical Therapy assessment which identified the resident as needing moderate assistance for repositioning in bed, and the MDS dated August 20, 2019 noting the resident's frequent incontinence of bowel and bladder, and that the resident required extensive assistance from two staff members to reposition in bed. .
The facility failed to provide appropriate interventions, including turning and repositioning, to prevent pressure ulcers from developing for Resident CL5, who was documented as needing moderate assisatance to extensive assistance with two staff members for bed mobility, and who was identified as being at risk for skin impairment due to immobility and frequent incontinence. The air mattress noted to be necesary on the care plan dated August 13, 2019 was not in place and was ordered again on August 26, 2019 when the unstagebale sacral wound was discovered, 13 days later. The facility also failed to identify and treat Resident CL5's sacral pressure ulcer before it became unstageable, even though staff documentation showed the application of barrier cream to the resident's buttocks area three times daily. This resulted in actual harm to Resident CL5 who developed an unstageable pressure ulcer to the sacrum.
The above information was conveyed to the Nursing Home Administrator and Director of Nursing on October 2, 2019 at approximately 3:15 p.m.
28 Pa. Code: 201.14(a) Responsibility of licensee
Previously cited 2/13/18, 8/28/18
28 Pa. Code: 201.18(b)(1) Management
Previously cited 8/28/18, 10/19/18, 2/22/19
28 Pa. Code: 211.5(f) Clinical records
Previously cited 2/22/19, 12/7/18, 10/19/18, 8/28/18, 2/13/18, 10/27/17
28 Pa. Code: 211.10(c) Resident care policies
Previously cited 3/15/18, 8/28/18, 10/19/18, 10/27/17
28 Pa. Code: 211.12(d)(1)(5) Nursing services
Previously cited 2/22/19, 8/28/18, 10/19/18, 4/16/18, 3/15/18, 2/13/18, 10/27/17, 10/5/17
| | Plan of Correction - To be completed: 11/15/2019
Resident CL5 has discharged from the facility and no longer resides here.
All Residents who are incontinent and require assistance with mobility are at risk for acquiring pressure ulcers. The interdisciplinary team will meet to review residents. Appropriate injury prevention measures will be implemented for those identified to be at risk.
When a resident is admitted into the facility a skin assessment will be conducted. In-servicing will be provided to all Nursing Staff to reeducate them on identifying residents that are at risk for acquiring pressure ulcers, appropriate interventions as well as obtaining appropriate orders to prevent the development of pressure areas.
CNA's will be in-serviced on identifying potential areas that should have further assessment by the licensed nursing staff.
When a resident is admitted into the facility a skin assessment will be conducted. Residents identified as being at risk for skin injury will have a weekly skin assessment conducted by licensed nursing staff.
The DON or designee will conduct a monthly audit X4 to ensure that all Residents have the appropriate interventions. Findings will be reported at our QAPI meetings to make recommendations.
All corrective actions will be completed by 11/15/2019
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