§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 facility policy and procedure review, clinical record review and staff interview it was determined the facility failed to provide care and service for pressure ulcers for one of three residents reviewed. (Resident 1)
Findings include:
Review of facility policy and procedure titled Wound Management Program, dated January 11, 2019, revealed The C.N.A. will observe resident's skin during care for signs and symptoms of skin breakdown and report concerns with skin integrity to nurse. Documenting findings in Point of Care Documentation.
Review of Resident 1's diagnosis list revealed the resident was admitted to the facility on February 15, 2024 with diagnosis of paraplegia (paralysis of the legs and lower body).
Review of Resident 1's Braden Scale for Predicting Pressure Score Risk, dated February 15, 2024 revealed the resident to be at high risk for pressure ulcers.
Review of Resident 1's Skin Observation tool dated February 16, 2024 revealed the resident was admitted with a Stage 4 pressure ulcer (full skin and tissue loss with muscle, bone or tendon exposed) to the sacrum (a triangular bone in the lower back formed), Stage 3 (full skin loss with fat exposed but no muscle, bone, or tendon exposed) pressure ulcers to the right knee and left heel and a stage 2 pressure ulcer (partial thickness loss of the skin presenting as a shallow open ulcer with a red or pink wound bed) to the scrotum.
Review of Resident 1's Wound Assessment Report, dated March 5, 2024 Revealed a stage 3 pressure ulcer to the left thigh 7 centimeters long, 3 centimeters wide and 0.2 centimeters deep that was new and acquired on March 5, 2023.
Interview with Licensed Nursing Employee E3 on March 9, 2023 at 11:30 a.m. revealed this wound was first discovered when the Wound CRNP (Certified Registered Nurse Practitioner) performed weekly wound rounds and should have been documented by staff prior to the wound advancing to this late stage.
28 Pa. Code 201.14(a) Responsibility of licensee
28 Pa. Code 201.18(b)(1)(3)(e)(1) Management
28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services
| | Plan of Correction - To be completed: 04/20/2024
1) caregivers involved in resident 1 care will be re-educated to skin assessment and wound prevention. Education by Director of Nursing, Wound Care Nurse. Signatures on file with NHA
2). Certified Nursing Aid and nurses to be re-educated to skin assessment process and wound prevention policy and procedure Including documentation. Education by Director of Nursing or Wound Care Nurses. Signature on file with NHA
3) resident 1 discharged from the facility and no update to documentation or care necessary.
4) head to toe skin assessment to be completed on all current residents who are high risk and/or currently have wounds. Tracking on file with NHA
5) wound tracking and trending to be monitored weekly by team and reported to QAPI Team Monthly.
6) wound prevention policy and procedure will be reviewed and updated as appropriate.
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