§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 ensure that residents receive necessary treatment and services consistent with professional standards of practice to promote healing and prevent infection for one of 10 residents reviewed (Resident 9).
Findings include:
Review of Resident 9's clinical record reveals diagnoses that included chronic kidney disease (CKD - a gradual loss of kidney function occurs over a period of months to years) and hypertension (high blood pressure).
Review of Resident 9's clinical record revealed the following treatment orders: Treatment 1: Pressure ulcer sacrum, cleanse with NSS (normal sterile saline), apply Santyl and cover with alginate and bordered foam dressing once a day and as needed every evening shift for wound, with a start date of December 1, 2023, and a discharge date of January 6, 2024; Treatment 2: Pressure ulcer sacrum, apply strength Dakins wet to dry and cover with bordered foam dressing every evening shift for wound, with a start date of January 6, 2024, and a discharge date of January 26, 2024; and Treatment 4: right heel, apply skin prep every evening shift, offload heels in bed, with a start date of December 22, 2023, and a discharge date of January 11, 2024.
Review of Resident 9's comprehensive person-centered care plan revealed a focus area of the following: Actual skin breakdown related to pressure ulcers, present on admission: Left buttock, right buttock, sacrum, and deep tissue injury on left and right heels, with an initiation date of December 2, 2023. Further, Resident 9's care plan intervention revealed for treatments to be administered per physician orders, with an initiation date of December 2, 2023.
Review of Resident 9's clinical record January 2024 TAR (Treatment Administration Record) revealed a blank space on January 5, 2024, for Treatment 1: pressure ulcer of the sacrum, indicating there was no evidence of the treatment being completed on Resident 9 on that day.
Further review of Resident 9's January 2024 TAR revealed January 6, 7, and 8, 2024, being blank for Treatment 2: pressure ulcer of the sacrum, indicating there was no evidence of the treatment being completed on those days.
Review of Resident 9's January 2024 TAR also revealed January 5, 6, and 7, 2024, being blank for Treatment 4: Right heel, indicating there was no evidence of the treatment being complete on Resident 9 on those days.
The facility was unable to provide any further documentation or evidence of the treatments above being completed on Resident 9.
During an interview with the Director of Nursing on February 12, 2024, at 2:26 PM, she revealed that she is not sure why Resident 9's January TAR treatments were not documented as being completed from January 5, 2024, through January 8, 2024, and would have expected staff to mark off on the TAR that the treatment was completed on Resident 9 after doing so.
28 Pa. Code 211.12(d)(1)(5) Nursing services 28 Pa. Code 211.12(d)(3) Nursing services
| | Plan of Correction - To be completed: 02/26/2024
1.Resident 9 was discharged from the facility on 1/31/2024. 2.Director of Nursing/designee will perform a facility wide audit on residents with current orders for wound care and identify any residents that have had missed documentation or missed wound treatments in the last 2 weeks. Residents identified as having missing documentation will be assessed for any negative outcome related to missed wound documentation or treatments. 3.Director of Nursing/designee will educate licensed staff on Ftag 686 and the importance of completing and documenting wound treatments as well as steps to take when a wound care treatment is not able to be performed for any reason. As part of the facility clinical meeting process clinical team will review missed wound treatment documentation for appropriate follow up. 4.Director of Nursing/designee will perform random sample audits of 5 residents with wound treatment orders to ensure wound treatments were completed and appropriately documented. These audits will be conducted weekly for 4 weeks and monthly for 2 months. Results of these audits will be reviewed by the Quality Assurance Performance Improvement committee for review and recommendations.
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