§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 and staff interview, it was determined that the facility failed to provide necessary treatment and services to promote healing of a pressure ulcer for one of two residents reviewed (Resident CR1).
Findings include:
Closed clinical record review for Resident CR1 revealed the resident was admitted to the facility from the hospital on December 15, 2023, after a fall and having right hip surgery. Resident CR1 had a change in condition and was admitted to the hospital on February 1, 2024. Resident CR1 was not in the facility at the time of the survey.
Review of a nursing admission assessment dated December 15, 2023, for Resident CR1 revealed that a Stage I (non-blanchable redness of a localized area over a bony prominence) pressure ulcer measuring 0.3 cm (centimeters) length x 0.2 cm width x 0.0 cm depth was observed on the resident's buttocks.
Review of a wound care consultant assessment dated December 19, 2023, revealed the consultant identified this pressure ulcer as a Stage I over the sacrum (the large flat bone in the lower part of the spine) that measured 1.3 cm length x 0.3 cm width x 0.5 cm depth.
Review of physician orders for Resident CR1's pressure ulcer dated December 20, 2023, were for the nurse to cleanse the sacrum with acetic acid 0.25% (solution to prevent wound infections), apply barrier cream (a cream used to provide skin protection from urine and feces), and apply a dry padded dressing every day and as needed. (Note that the wound consultant notes were not available immediately, which accounts for the treatment not starting on the date the resident was seen).
Review of the TAR (treatment administration record, form for documenting the treatment provided as ordered by the physician) for Resident CR1 dated December 21 through December 27, 2023, revealed no initials in the date of December 24, 2023. Interview with the Director of Nursing on February 2, 2024, at 3:00 PM revealed if the treatment was not signed for this indicated the treatment was not provided.
Review of a wound care consultant assessment dated December 26, 2023, revealed the consultant identified this pressure ulcer as a Stage I that measured 1.3 cm length x 0.3 cm width x 0.1 cm depth.
Review of a wound care consultant assessment for Resident CR1 dated January 2, 2024, revealed the pressure ulcer declined to a Stage II (a partial-thickness skin loss with exposed dermis, presenting as a shallow open ulcer), that measured 1 cm length x 0.3 cm width x 0.1 cm depth.
Review of the TAR for Resident CR1 dated December 28, 2023, through January 10, 2024, revealed the nurse was to cleanse the sacrum with acetic acid 0.25 %, apply collagen fibers (a special fiber that promotes healing and growth of new skin), zinc (cream formulated for healing and protecting the skin), and apply a dry padded dressing every day and as needed. Review of the TAR revealed no initials in the dates of December 30, 2023, and January 4, 5, and 10, 2024, indicating the treatment was not provided on those dates.
Review of a wound care consultant assessment for Resident CR1 dated January 9, 2024, revealed the pressure ulcer declined to a Stage III (full thickness tissue loss, subcutaneous fat may be visible, but bone, tendon or muscle is not exposed, may include undermining and tunneling) that measured 2 cm length x 4 cm width x 0.1 cm depth.
Review of the TAR for Resident CR 1 dated January 11 through 16, 2024, indicated the nurse was to cleanse the ulcer with Normal Saline Solution (fluid like normal body fluid), pat dry, apply collagen fibers, zinc, and a dry padded dressing daily and as needed. The TAR indicated that the resident received the physician ordered treatment daily as ordered.
Review of a wound consultant assessment for Resident CR 1 dated January 16, 2024, revealed the sacral wound healed.
The facility failed to provide physician ordered treatments to Resident CR1's pressure ulcer on the above dates to promote healing.
During an interview with the Director of Nursing on February 2, 2024, at 3:00 PM confirmed the above findings.
28 Pa Code 211.10(d) Resident care policies
28 Pa Code 211.12(d)(1)(5) Nursing services
| | Plan of Correction - To be completed: 03/12/2024
Unable to retro-actively correct, as resident CR1 is no longer in the facility.
UM/designee will complete a house audit of all residents with orders for treatments in the past 10 days to ensure that treatments were completed per physician order. Any residents determined to have not received their treatment will be assessed by the nurse to determine the need for further intervention.
Licensed nursing staff will receive education regarding completing treatments as ordered and signing them off in the medical record.
UM/designee will complete random audits of treatments 3x/week to ensure that treatments are completed per physician order.
Results of these audits will be reported to the QA Steering Committee monthly x3 months, at which time the committee will determine the need for future audits.
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