|§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 clinical record review, observation and staff interview, it was determined that the facility failed to provide wound care treatment in accordance with physician's orders for one of five sampled residents. (Resident 2).
Clinical record review revealed that Resident 2 had diagnoses that included diabetes, chronic pain, and peripheral vascular disease (a condition that affects blood circulation to the limbs). A physician's order dated November 20, 2019, directed staff to cleanse the residents' left heel ulcer and cover with a dry sterile dressing once daily. Observation on January 17, 2020, at 9:05 a.m., revealed that Resdient 2 had a white bandage on his left foot that was dated January 14, 2020. Staff failed to clean and change the dressing for two days (January 15, and January 16, 2020).
In an interview on January 17, 2020, at 9:05 a.m., Resident 2 stated "they have not changed the dressing or cleaned my foot since the fourteenth."
In an interview on January 17, 2020, at 2:20 p.m., the Director of Nursing confirmed that the left foot heel dressing had not been cleansed and changed as per the physician order since January 14, 2020 at 2:30 p.m.
28 Pa. Code 211.12 (a)(1)(5) Nursing Services
Previously cited 5/31/19, 4/6/19, 11/2/18
| ||Plan of Correction - To be completed: 02/18/2020|
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truths or facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed in accordance with federal and state law requirements.
Resident(R2) dressing was changed
Current residents with wound care orders will be reviewed by DON/Designee to ensure treatment is being done in accordance with doctor's orders
Licensed nurses will be reeducated by DON/Designee on following wound care orders
DON/Designee will audit monthly x 3
Audit results will be reported to the QA committee for further recommendation