Pennsylvania Department of Health
Patient Care Inspection Results

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Inspection Results For:

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AVENTURA AT PEMBROOKE - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Findings of an Abbreviated Complaint Survey completed on March 21, 2024, at Aventura at Pembrooke, identified a deficient practice, related to the reported complaint allegations, under the requirements of 42 CFR Part 483, Subpart B Requirements for Long Term Care Facilities and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations as they relate to the Health portion of the survey process.

 Plan of Correction:

483.25(b)(1)(i)(ii) REQUIREMENT Treatment/Svcs to Prevent/Heal Pressure Ulcer:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
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 a review of the facility's policy, clinical records review, and staff interview, it was determined that the facility failed to comprehensively assess a wound identified upon admission and failed to place a treatment order timely for one of three residents reviewed (Resident CL1).

Findings include:

Review of the facility's policy titled "Wound Care Management", undated revealed that all residents are assessed on admission, quarterly, and with a change of condition. Documentation will include the length, width, and depth of the wound and the appearance of the wound.

Review of Resident CL1's clinical records revealed Resident CL1 was admitted to the facility on February 20, 2024, with a diagnosis of Sepsis - (The body's extreme reaction to an infection, without prompt treatment can lead to organ failure, tissue damage, and death).

Review of Resident CL1's clinical record including "Nursing Admission Screening/History" dated February 20, 2024, at 5:30 p.m., revealed a resident with a wound on the sacrum (tail bone) with a measurement of 5.0 x 3.0 x 3.0 cm. The wound assessment revealed no information regarding the wound's appearance which includes wound bed, drainage, etc. The same form revealed "Wound treatment or required" to cleanse the wound with normal saline, apply Medihoney- (A dressing that aids and supports debridement and a moist wound healing environment in acute and chronic wounds and burns), and cover with a dry dressing.

Review of Resident CL1's clinical record failed to reveal that the Medihoney wound treatment was put in as an order and therefore was not transcribed into the resident's Treatment Administration Record.

Interview with licensed nurse Employee E3 was conducted on March 21, 2024. Employee E3 reported that the nursing supervisor was responsible for assessing wounds identified on admission. Employee E3 confirmed that the initial wound assessment was not done comprehensively. Employee E3 reported that an agency nurse worked that day and was unable to say the reason why the wound treatment on Resident CL1's sacrum was not ordered.

Review of Resident CL1's clinical record including wound consult dated February 21, 2024, revealed that Resident CL1's wound was assessed and evaluated by the wound physician. The sacral wound was identified as Unstageable (Obscured full-thickness skin and tissue loss) necrosis, measuring 3.0 x 2.5 x 0.5 cm, 50% thick adherent necrotic tissue, with light serous drainage. The treatment plan is as follows: Leptospermum Honey is applied once daily covered with bordered dressing daily for 30 days.

Review of Resident CL1's clinical record revealed Leptospermum wound treatment for Resident CL1's unstageable necrosis wound to sacrum was not put in as an order until February 23, 2024, two days after the wound treatment recommendation was made by the wound physician.

Interview with Employee E3 on March 21, 2024, revealed that she/he was with the wound physician during the consultation on February 21, 2024, but the physician did not mention a wound treatment order. Employee E3 reported that the consultation form which had the information of the resident's wound assessment/evaluation and recommended treatment plan was not received by the facility until February 23, 2024.

Review of Resident CL1's clinical record revealed Resident Cl1's unstageable necrosis sacral wound treatment order was not implemented until February 23, 2024, three days after the wound was identified on admission day.

The above information was discussed with the Nursing Home Administrator and Director of Nursing on March 21, 2024.

The facility failed to ensure Resident CL1's unstageable sacral wound was comprehensively assessed upon admission and treatment order was put in place timely.

28 Pa. Code 211.5(f) Clinical records

28 Pa code 211.10 (c) Resident care policies

28 Pa. 211.12(c)(d)(1)(3)(5) Nursing services

 Plan of Correction - To be completed: 04/05/2024

The resident in question no longer resides in the facility and unable to complete a correction of the alleged deficiency of practice.

A skin assessment audit of all current residents will be completed to ensure all skin alternations have a corresponding treatment order in place. Any variations will be corrected with treatment orders put in place.

All nursing staff will be educated on the process of identifying skin alternations and ensuring a treatment order is in place.

An audit of all new admissions will be completed weekly x 4 then monthly x 2 to ensure all new residents have treatment orders in place on admission.

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