Based on observations, review of select facility policies, facility investigative documentation, clinical record review, and staff interviews, it was determined the facility failed to consistently provide care and services to prevent the development of pressure ulcers and to promote healing of existing wounds for one resident (Resident 2) out of 21 sampled residents.Findings include:
According to the US Department of Health and Human Services, Agency for Healthcare Research & Quality, the pressure ulcer (a localized area of skin damage that develops when prolonged pressure is applied to the body) 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 areas of risk.
ACP (The American College of Physicians 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 facility policy entitled "Pressure Ulcer/Injury Care and Management" last reviewed January 22, 2025, revealed residents will receive care consistent with professional standards of practice, to prevent pressure ulcer/injury unless the individual's clinical condition demonstrates they were unavoidable. Residents will receive necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing. Residents with a pressure ulcer will have wound measurements weekly by the physician or registered nurse. Observation of the wound should be completed with each dressing change and should include at a minimum:
A.Location and staging
B.Size, depth, the presence and location of any undermining or tunneling
C.Exudate if present the type, color, odor, and amount
D.If pain is present the nature and frequency
E.Wound bed to include the color and type of tissue
F.Description of the wound edges
A review of Resident 2's clinical record revealed admission to the facility on May 12, 2021, with diagnoses, which included dementia, a history of blood clots in the lower legs and peripheral insufficiency (decreased blood flow to the lower legs) and has been receiving hospice services since October 17, 2024, for a diagnosis of senile degeneration of the brain (dementia).
A review of a Quarterly Minimum Data Set assessment dated January 21, 2025, (MDS - a federally mandated standardized assessment process completed periodically to plan resident care) revealed the resident was severely cognitively impaired and was at risk for developing pressure ulcers.
A review of a quarterly Braden scale for predicting pressure sore risk assessment dated January 30, 2025, revealed the resident responded to verbal commands but cannot always communicate discomfort or the need to be turned or has some sensory impairment which limits the ability to feel pain or discomfort. The resident walks occasionally and was at risk for pressure ulcer development.
A review of Resident 2's comprehensive care plan, initially developed on May 13, 2021, identified the resident as being at risk for skin breakdown related to incontinence and the need for extensive assistance with activities of daily living. The care plan included a goal that the resident would have no additional skin breakdown. Interventions to address this risk included: monitoring the resident's skin condition daily during care and reporting any areas of redness or open skin to nursing and medical staff; use of a pressure-reducing mattress on the resident's bed (identified as the facility's standard pressure-reducing mattress); use of a pressure-reducing cushion in the resident's chair (a chair pad); and completion of biweekly skin assessments in conjunction with showers.
However, a review of the facility's "Documentation Survey Report" for April 2025 revealed that Resident 2 experienced daily episodes of bowel and bladder incontinence. Despite this, there was no documented evidence that incontinence care was consistently provided with each episode or that a barrier cream was applied as required by the resident's needs and consistent with professional standards of practice. This lack of documentation suggests that interventions identified in the resident's care plan were not consistently implemented to prevent the development or worsening of skin breakdown.
A nurse's note dated April 11, 2025, at 10:43 AM, documented that Employee 5 (LPN) was called to Resident 2's room by another staff member to evaluate a potential wound. Upon assessment, Employee 5 noted the presence of an open area located in the intergluteal cleft (the area between the right and left buttocks, only visible when the skin is separated). The wound bed contained light yellow slough (occlusive dead tissue), and the area was moist with no observable drainage. The surrounding peri-wound skin appeared flesh-toned and intact. The resident, who was incontinent of bowel and bladder, was also noted to intermittently refuse incontinence care, repositioning/offloading, and showers. The resident expressed no pain or discomfort at the time of assessment. The physician was notified, and new treatment orders were received for the application of calcium alginate with silver, a dry cover dressing, and the addition of a low air loss mattress to the resident's bed.
A review of a witness statement dated April 11, 2025, at 11:30 AM, revealed that Employee 5 (LPN) stated he had been informed by another unidentified staff member (no witness statement available at the time of the survey to identify this staff member) of a possible area of skin concern on the resident's buttocks. Following this notification, Employee 5 assessed the resident and confirmed the presence of a small slit-like open area in the intergluteal cleft. The RN Supervisor was also notified and conducted an additional assessment of the area.
A review of the initial skin assessment completed by Employee 5 (LPN) on April 11, 2025, described the wound in the intergluteal cleft as unstageable (defined as full-thickness tissue loss in which the base of the ulcer is covered by slough-yellow or white dead tissue). The slough measured 3.5 cm x 0.5 cm, and the surrounding skin remained flesh-toned and intact.
Further review of the clinical record revealed subsequently, documented at 10:43 AM on the same day, the Infection Preventionist (LPN) was called to evaluate Resident 2's wound. The LPN documented a wound in the intergluteal cleft, only found when the skin was pulled apart, with light yellow slough in the wound bed, moist but without drainage. The peri-wound skin was flesh-toned and intact. The resident was noted to be incontinent of bowel and bladder and occasionally refused incontinence care, repositioning, and showers. The Certified Registered Nurse Practitioner (CRNP) and the contracted wound physician were notified, and new recommendations included the application of calcium alginate with silver covered with a dry dressing and the use of a low air loss mattress.
At 11:02 AM, the facility CRNP evaluated the resident's wound, noting the presence of a wound in the intergluteal cleft, only found when the skin was pulled apart. The area was open with light yellow slough in the wound bed, moist but without drainage. The peri-wound skin was flesh-toned and intact. The resident was incontinent of bowel and bladder and occasionally refused incontinence care, repositioning, and showers. The physician was notified, and new recommendations included the application of calcium alginate with silver covered with a dry dressing and the use of a low air loss mattress.
A review of the shower records indicated that Resident 2 received a shower on April 12, 2025, during the 3 PM to 11 PM shift. Documentation from this time did not note any skin impairments.
On April 13, 2025, at 8:30 AM, Employee 7 (CNA) reported discovering skin openings on Resident 2's right side near the hip area during routine brief changing. The nurse was promptly notified.
Subsequently, at 8:50 AM, Employee 5 (LPN) documented in the nursing notes that during morning care, two small, reddened areas were observed on Resident 2's right buttock. The first area measured 2 cm x 2 cm, and the second measured 1.5 cm x 1.5 cm. These areas were not present during the skin assessment conducted during the resident's shower on April 12, 2025. The physician was notified, and treatment orders were obtained. The resident was scheduled to be seen by the consultant wound physician during weekly wound rounds.
A witness statement from Employee 5 (LPN), dated April 13, 2025, at 11:00 AM, corroborated the earlier findings, stating that during morning care, the nurse aide reported two small, reddened areas on Resident 2's right buttocks. The right proximal buttock had an open area measuring 2 cm x 2 cm, and the right distal buttock measured 1.5 cm x 1.5 cm. These areas were not present during the skin assessment completed by Employee 5 during the resident's shower on April 12, 2025.
A skin assessment completed by Employee 8 (Agency RN Supervisor) on April 13, 2025, revealed that the proximal right buttock exhibited Moisture Associated Skin Damage (MASD), measuring 2 cm x 2 cm x 0.5 cm, with surrounding skin noted as "normal tissue." The distal right buttock also exhibited MASD, measuring 1.5 cm x 1.5 cm x 0.5 cm, with surrounding skin noted as "normal tissue." A physician's order was noted to cover the area with a foam border daily and as needed and consult wound care team.
A review of a consultant wound assessment dated April 15, 2025 (two days after identification of the wounds), revealed the following pressure injuries for Resident #2:
Coccyx Area: A Stage 2 pressure ulcer (open area through layer of skin creating shallow open wound) measuring 2.3 cm (length) x 0.5 cm (width) x 0.2 cm (depth) was observed. The wound bed exhibited exposed dermis with moderate serosanguinous drainage.
Right Superior Buttock: A Stage 2 pressure ulcer measuring 0.6 cm x 0.6 cm x 0.1 cm was noted, presenting with an open wound bed, exposed dermis, and moderate serosanguinous drainage.
Right Inferior Buttock: A Stage 2 pressure ulcer measuring 0.6 cm x 0.5 cm x 0.1 cm was identified, also displaying an open wound bed with exposed dermis and moderate serosanguinous drainage.
In response to these findings, the wound consultant ordered the application of calcium alginate with silver dressings to all three pressure ulcers. The treatment plan specified that the dressings be covered with gauze and changed daily and as needed.
Calcium alginate with silver dressings are recognized for their high absorbency and antimicrobial properties, making them suitable for managing moderate to heavily exuding wounds and reducing the risk of infection.
After the identification of pressure areas on April 11 and April 13, 2025, the following wound prevention interventions were documented:
On April 13, 2025, prompted toileting was initiated at 7 AM, 10 AM, 6 PM, 9 PM, and as needed.
On April 17, 2025, the application of barrier cream to the buttocks with each incontinence episode was implemented.
On April 18, 2025, a turning and repositioning schedule every 2-3 hours was established.
However, a continence evaluation was not completed until April 23, 2025, despite the resident's increased incontinence.
Additionally, there was no evidence that the physician-ordered low air loss mattress was placed on the resident's bed until April 13, 2025.
Observations conducted on April 22nd, 2025, revealed that Resident 2 was seated in his wheelchair at multiple times: at 9:30 AM outside of his room, at 11 AM in the activity room, and at 12:30 PM prior to being returned to bed for evaluation by the contracted wound consultant. During all three observations, the resident was utilizing the gel cushion on his wheelchair.
The resident utilized a gel cushion on his wheelchair, which was noted to be very worn, uneven, and lacking support. The cushion was also dirty with dried food and liquid stains. These observations were confirmed by the infection control/wound nurse.
An observation conducted on April 22, 2025, of Resident 2's sacral wound, in the presence of the contracted wound physician, measured 1.8 cm x 0.3 cm. The physician stated that the depth could not be measured due to the presence of "dermal" skin in the center of the wound, which was white in color. A scant amount of serosanguinous drainage was noted, with the wound bed appearing pink/red and the surrounding skin blanchable.
Further observations of the upper and lower right buttock areas revealed wounds measuring 0.3 cm x 0.4 cm and 0.4 cm x 0.3 cm, respectively. Both wound beds were white, with surrounding skin blanchable and a scant amount of serosanguinous drainage noted.
There was no evidence of a thorough investigation into the development of these pressure areas to identify possible causes and corresponding interventions. Additionally, interventions were not timely implemented to prevent the pressure areas for this resident, who was at risk for pressure sore development.
During an interview conducted on April 23, 2025, at 2:00 PM, the Director of Nursing confirmed that an investigation was not completed into the development of the noted pressure areas and further confirmed that interventions were not timely implemented for this resident to prevent the development of pressure areas.
28 Pa code 211.12 (d)(1)(3)(5) Nursing services
