Deficiency Text Not Available

Complaint #152805, #153069 Based on observations, interviews, review of medical records and other facility documentation, it was determined that the facility failed to ensure: a) there was no delay for physician ordered wound treatment that was not initiated for 17 days, b) Care Plan (CP) interventions to prevent skin breakdown were consistently implemented, c) ensure staff were competent to administer physician ordered wound treatments, and d) a comprehensive assessment was completed to ensure thorough identification of PU risk. The facility also failed to follow the facility pressure ulcer policy to accurately assess and prevent the worsening for a resident assessed as being at risk for pressure ulcers who was initially identified with a full-thickness Stage 3 (tissue loss-fat may be visible) pressure ulcer (PU) to the left gluteus and Stage 2 PU to the sacrum. The deficient practice occurred for 1 of 2 residents (Resident #39) reviewed for PU, who was initially identified with the PU's on 04/19/23 (over eight months prior) and was evidenced by the following: On 01/05/24 at 11:57 AM, the surveyor toured the 300 Unit of the facility and observed Resident #39 in bed with the head of the bed elevated and the resident was facing the door. Resident #39 smiled when the surveyor approached and appeared very frail. When the surveyor inquired regarding the resident's status, the Certified Nursing Aide (CNA) observed in the hallway informed the surveyor that the resident preferred to stay in bed. On 01/05/24 at 12:45 PM, the surveyor returned to the room and observed Resident #39 in bed, in the same position as observed at 11:57 AM, facing the door and his/her eyes were closed. On 01/09/24 at 9:41 AM, the surveyor observed the resident in bed, mostly nonverbal, and smiled when approached. Resident #39 did not engage in any conversation with the surveyor. The resident was positioned onto the left side and was facing the door. On 01/09/24 at 12:10 PM, the surveyor returned to the room and observed the resident in bed, in the same position as observed at 9:41 AM (approximately 2.5 hours later) on their left side. On 01/10/24 at 8:50 AM, the surveyor observed the resident in bed, positioned on their back and the head of the bed was elevated. On 01/10/24 at 10:15 AM, the surveyor returned to the room and observed the resident in bed in the same position as noted at 8:50 AM. The surveyor attempted to engage with the resident, but the resident was mostly nonverbal and only smiled. During an interview with the CNA who cared for Resident #39, he stated that he provided morning care to the resident and was just waiting for the nurse to redress the sacral wound. On 01/10/24 at 10:29 AM, observation and interview with the Registered Nurse Unit Manager (RN/UM) and the Licensed Practical Nurse (LPN) during the wound treatment, revealed that Resident #39 had one pressure ulcer to the sacral area (the original ulcers identified on 04/19/23 were now combined). The surrounding pressure ulcer wound area appeared very excoriated and reddened. The LPN cleansed the wound and the surrounding areas and applied the border gauze directly to the reddened and excoriated areas. On 01/10/24 at 12:30 PM, the surveyor reviewed Resident #39's medical record. The admission Face Sheet (an assessment summary) reflected that Resident #39 was admitted to the facility with diagnoses which included but were not limited to; Parkinson's Disease, essential hypertension, abnormal posture, difficulty in walking, and unspecified abnormality of gait (walking) and mobility. The Annual Minimum Data Set (MDS) a resident assessment tool used by the facility to prioritize care, dated 11/16/2023, revealed that Resident #39 was alert and able to make his/her needs known. Resident #39 scored 11 out of 15 on the Brief Interview for Mental Status (BIMS), which indicated the resident had a moderate cognitive impairment. Section GG of the MDS which addressed Functional Status with activities of daily living, indicated Resident #39 was totally dependent on staff for mobility and transfer. Section M - Skin Conditions, revealed that Resident #39 had one stage 4 (full thickness tissue loss with exposed bone, tendon or muscle) pressure ulcer to the sacrum area. Review of the Order Summary Report dated 01/22/24, did not reflect an order for skin assessment. However, review of the Task List Report provided by the facility with an original date of 04/07/21, reflected an order for Skin Observation every day every shift. Day 7-3, Night 11-7, Evening 3-11. A review of the 1/2024 Treatment Administration Record (TAR) failed to reveal an order for skin assessments. Review of the Weekly Skin Reviews from 01/18/23 to 04/13/23, provided by the facility revealed that Resident #39's skin was intact. There was no documented evidence that staff reported any skin impairment during care prior to 04/29/23 (when the State 3 wound was identified). The facility was unable to provide a skin assessment for 04/20/23, and the Director of Nursing (DON) stated that she was unable to locate a skin assessment. The DON provided the surveyor with an investigation regarding the wound, dated 04/19/23. The investigation did not include a causal factor or summary regarding the failure for the delay to identify any skin impairment prior to the initial identification of the stage 3 wound with slough. Review of the investigation report provided revealed that the wound was identified on 04/17/23. The family was notified on 04/17/23 and the physician was notified on 04/19/23(two days later). On 01/11/24 at 9:15 AM, during an interview with the DON, she stated that she could not provide a rationale for Resident #39, who was totally dependent on staff for care to, developed a facility acquired PU, identified at Stage 3 with slough. When inquired if it was possible based on the level of care required by the resident, the DON stated, It could happen but declined to elaborate further. Resident #39 failed to have a documented turning/repositioning schedule in place, and the facility was unable to provide documentation that Resident #39 had been turned and repositioned at least every 2 hours per facility policy. Resident #39 was referred to Occupational Therapy on 04/20/23. The Occupational Therapy Evaluation and Plan of Treatment revealed that the resident had been bedbound for more than a year and had advanced Parkinson with no motor control of bilateral lower and upper extremities. Resident #39 was totally dependent on staff for all activities of daily living including self-feeding. Occupational Therapy provided caregiver education to her CNA regarding use of positioning wedges, offloading heels, and instituting a turning schedule for pressure relief. These recommendations were not entered on the CP as interventions. A further review of the Physician Order Summary dated 01/22/24 failed to reveal physician orders for a turning schedule. Review of the [name redacted] wound consult initiated 04/21/2023, two days after the facility identified the wound, noted the following: Patient [referring to Resident #39] is seen for follow up and management of wounds. Resident is non-verbal at the time of the examination. Social History: The resident is deemed an unreliable historian. The above information was obtained from facility records, staff report. Staff reports, urinary and fecal incontinence, poor bed mobility, weakness, skin ulcerations . Wound 1: Positive for full thickness ulceration of the left gluteus/ gluteal region 4.5 centimeter (cm) x 2.0 cm x 0.1 cm wound base 90% granular, 10% slough. periwound with dark discoloration without erythema, induration, edema or crepitus. Wound 2: Partial thickness ulceration of the sacral region, 0.9 cm x 0.5 cm x 0.1 cm wound base clean. pink. Plan: Decrease size: Unstageable previously classified as Stage 3 pressure ulcer/ injury of the left gluteus due to slough. Analysis: with slough: wound found by staff on 04/19/23. Contributing factors: reduced mobility and incontinence. Apply [name redacted] (debriding agent) to wound base, cover with gauze then bordered gauze daily and as needed, for soilage /dislodgement. Continue repositioning in accordance to assessed needs. Off-load pressure to affected areas. Apply Zinc based moisture barrier on periwound and perisacral region every shift and as needed. Monitor nutritional intake. Review of Resident #39's facility provided CP revealed an undated focus area for potential for pressure ulcer development related to disease process, immobility. The goal was for Resident #39 to have intact skin, free of redness, blisters, or discoloration by /through review date. The interventions included: Follow facility policies/protocol for the prevention/ treatment of skin breakdown. Inform the resident/family care givers of any new area of skin breakdown. Low air loss mattress as ordered at 4 bars. Monitor nutritional status. Serve diet as ordered, monitor intake and records. The resident needs: encouragement, assistance, supervision with use of siderails, trapeze bar, etc; for resident to assist with turning. Another undated focus revealed: Resident #39 has actual impairment (MASD - moisture associated skin damage) to skin integrity of the left buttock. The goal: Resident #39 will be healed by review date (unspecified). Interventions included: Encourage good nutrition and hydration in order to promote healthier skin. Follow facility protocols for treatment of injury. Monitor, document location, size, and treatment of skin injury. Report abnormalities, failure to heal, s/sx [signs and symptoms of infection, maceration etc. to MD. An intervention to turn and reposition the resident at least every 2 hours was not included in the CP, not prior or, after the pressure ulcer was identified on 04/19/23. There were no updated goals or interventions to promote healing or prevent worsening of the sacral wound identified on 04/19/23. Review of the Braden Scale for predicting Pressure Sores Risk dated 04/19/23, revealed that Resident #39 was assessed to be at moderate risk for pressure sores. Resident #39 had a score of 14 which indicated being at moderate risk. However, on the 7 points scoring for Braden Scale Assessment: Resident #39 should have a score of 1 for sensory perception, 1 for moisture, 1 for constantly moist (incontinent of bowel and bladder) and Activity should have been coded as 1. Resident #39 had been bedfast for over a year according to the Occupational Therapy documentation. Chair fast was rated. Mobility: Resident #39 received a score of 2 for being very limited, while Resident #39 had been completely immobile. Nutrition was coded as a 2. During the investigation dated 04/17/23, Resident # 39 was identified by the facility as having poor skin turgor, poor appetite, contracture, and muscle wasting. On 01/11/24 at 8:50 AM, the surveyor completed a subsequent interview with the UM regarding the physician ordered wound treatment for Resident #39. The UM stated that there were no other treatments ordered for the wound. The surveyor then reviewed the wound treatment recommendations with the UM. The UM was not aware, that the treatment ordered on 12/26/23, had not been transcribed on the treatment administration record. After surveyor inquiry, the UM transcribed the order on 01/11/24, this was 17 days after the order was received. On 01/11/24 at 9:15 AM, the surveyor observed Resident #39 in bed laying on his/her backside. Resident #39 had remained in bed in the same position during the morning shift. At 10:30 AM, the surveyor asked the CNA to come to the room to check Resident #39. At that time the surveyor had observed that Resident #39's incontinent brief was saturated with urine. The CNA stated that he would provide incontinence care after breakfast was completed. On 01/11/24 at 9:45 AM, the surveyor discussed the wound observation and the treatment that was not transcribed from 12/26/23 through 01/11/24, with the DON. The DON stated, in the presence of the survey team, that the UM was responsible to review and transcribe the order on the TAR. The DON was also made aware that Resident #39 was observed on several occasions in the same position for more than two hours during the survey. The DON stated that repositioning should have occurred every two to three hours during the shift. On 01/11/24 at 10:29 AM, the surveyor, again reviewed the wound care treatment order for Resident #39's sacral area. The LPN failed to follow the treatment ordered per the surveyors observation of wound care on 01/20/24 at 10:29 AM. The wound care practioner's order, dated 12/26/23, was to cleanse the wound with 0.125% Dakins solution. Primary treatment: Silver Alginate, apply zinc oxide ointment/ triamcinolone 0.1% cream/nystatin cream in 1:1 mix to periwound. covered with gauze then apply bordered gauze. During the observed treatment, the LPN cleansed the wound with the Dakins solution, apply silver alginate inside the wound and applied the bordered gauze. The LPN omitted to apply gauze to cover the dressing as ordered and failed to apply the tramcinolone and Zinc Oxide to the periwound. On 01/11/24 at 11:30 AM, the surveyor interviewed the CNA who cared for Resident #39 during the 7:00 AM to 3:00 PM shift. The CNA stated that Resident #39 had been unable to feed self and could not turn and reposition self. The CNA stated that Resident #39 was totally dependent on staff and required extensive assistance with all activities of daily living. Per the CNA, Resident #39 had not been out of the bed because he/she preferred to stay in bed. The CNA further stated, in the morning he provided incontinence care, changed, fed the resident, and assist with positioning the resident for the wound care. He would check on the resident at the end of the shift. When inquired about how he communicated with the resident, he stated that you must face the resident and read his/her lips. On 01/11/24 at 12:30 PM, the surveyor interviewed the UM regarding repositioning for Resident #39. The UM informed the surveyor that the resident was on a low air loss mattress. The surveyor then asked the UM if a resident on a pressure reducing mattress could be turned and repositioned. The UM declined to comment and stated that she would get back to the surveyor. On 01/17/24 at 9:05 AM, the surveyor observed Resident #39 in bed, facing the door and was awake and alert. On 01/17/24 at 12:41 PM, the surveyor observed Resident #39 in bed facing the door in the same position as observed at 9:05 AM (3.5 hours after the last observation). The surveyor interviewed the CNA regarding the care required by the resident. The CNA stated that he assisted the resident with meals, changed the resident in the morning, and assist with wound care. He will change the resident again after lunch. The CNA did not address the need to reposition the resident every 2-3 hours. The resident would be provided with incontinence care in the morning and prior to the end of the shift. The facility could not provide any documentation regarding repositioning every 2-3 hours. On 01/22/24 at 9:05 AM, the surveyor observed the CNA at the bedside. At the surveyor's request, the CNA asked the resident if he/she was provided with incontinence care this morning. The resident stated that he/she was cared for last night not this morning. The CNA proceeded to check the resident. Resident #39 was incontinent of urine and feces. There was no dressing in place to protect the wound which was directly exposed to the urine and feces. The surveyor requested the UM to come to the room where we all observed that the resident was soiled with urine and feces and there was no dressing in place to protect the wound. The treatment ordered was to change the dressing daily and as needed for soilage and dislodgement. The wound, that was identified eight months prior, on 04/19/23, had increased in size. Per review of the Wound Assessment Report completed by the Wound Care Consultant, dated 01/09/2024, the wound was now 8 cm (centimeters) in length, Width was 4.5 cm and the Depth was .5 cm. The etiology was Pressure and the wound was now a Stage 4 (Full thickness tissue loss with exposed bone, tendon or muscle). The Periwound (surrounding area of the wound edge) was Dermatitis, Fungal. Review of additional Wound Assessment Reports revealed: 04/21/23 full thickness ulceration of the left gluteus 4.5 cm x 2.0 cm x 0.1 cm. Partial thickness of the sacral region 0.9 cm x 05 cm x 0.1 cm. 04/23/23 Full thickness ulceration of the left gluteus /and sacral region now combined into one large wound. Full thickness of the left sacral region 5.0 cm x 10.0 cm wound base 30% granular 70 % slough. edges adherent to wound base. Moderate, malodorous serous drainage. 04/30/23 Full thickness ulceration of the sacral region. 9.0 cm x 10.0 cm with 40 % slough. wound with malodorous serous drainage. 06/07/23 full thickness ulceration of the left sacral region. 7.5 cm x 9.0 cm undermining 5.0 cm with moderate malodorous drainage. On 01/22/24 at 12:45 PM, the UM revealed in the presence of another surveyor that the wound should be covered to prevent infection and promote wound healing. On 01/22/24 at 1:20 PM, a telephone interview with the CNA who cared for the resident during the 11:00 PM-07:00 AM shift, revealed that he provided incontinence care to Resident #39 around 5:30 AM. The sacral wound dressing was soiled with feces and was noted in the soiled brief. He further stated that he forgot to inform the nurse. When asked why the wound should be covered, he stated, to prevent the wound from being infected. On 01/23/24 at 9:50 AM, during the pre-exit conference, regarding the wound, the DON stated, This is not what I expected . The DON stated that she could not explain it, the nurse went rogue, and hopefully it is an isolated situation. The DON stated the nurse should have clarified the wound treatment prior to the dressing change. Education on wound care will now be incorporated in QAPI (Quality Assurance Performance Improvement). The DON further stated that the UM was not aware of the recommendations and failed to transcribe the treatment order on the TAR. The DON confirmed the resident did not receive the prescribed wound treatment. A review of the facility provided form titled, Prevention of Pressure Ulcers/ Injuries last revised 1/2023, revealed the following: Purpose The purpose of this procedure is to provide information regarding identification of pressure ulcer/injury risk factors and interventions for specific risk factors. Preparation Review the resident's care plan and identify the risk factors as well as the interventions designed to reduce or eliminate those considered modifiable. Risk Assessment 1. Assess the resident on admission for existing pressure ulcer/injury risk factors. Repeat the risk assessment weekly and upon any changes in condition. 2. Conduct a comprehensive skin assessment upon admission, including: a. Skin integrity - any evidence of existing or developing pressure ulcers or injuries; b. Tissue tolerance - the ability of the skin (and supporting structures) to endure the effects of pressure; and c. Areas of impaired circulation due to pressure from positioning or medical devices. 3. Inspect the skin on a daily basis when performing or assisting with personal care or ADLs. a. Identify any signs of developing pressure injuries (i.e., nonblanchable erythema). For darkly pigmented skin, inspect for changes in skin tone, temperature, and consistency; b. Inspect pressure points (sacrum, heels, buttocks, coccyx, elbows, ischium, trochanter, etc.); c. Wash the skin after any episodes of incontinence; d. Moisturize dry skin daily; and e. Reposition resident as indicated on the care plan. Prevention Moisture 1. Keep the skin clean and free of exposure to urine and fecal matter. Nutrition 1. Monitor the resident for weight loss and intake of food and fluids. 2. Include nutritional supplements in the resident's diet to increase calories and protein, as indicated in the care plan. Mobility/Repositioning 1. Choose a frequency for repositioning based on the resident's mobility, the support surface in use, skin condition and tolerance, and the resident's stated preferences. 2. At least every two hours, reposition residents who are reclining and dependent on staff for repositioning. 3. Reposition more frequently as needed, based on the condition of the skin and the resident's comfort. 4. Teach residents who can change positions independently the importance of repositioning. Provide support devices and assistance as needed. Remind and encourage residents to change positions. Monitoring 1. Evaluate, report and document potential changes in the skin. 2. Review the interventions and strategies for effectiveness on an ongoing basis. The Care Plans, Comprehensive Person-Centered policy Adopted 11/2018 revealed: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. 13. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' condition change. The Nurse Manager, Job Description revealed: Review medication cards for completeness of information, accuracy in the transcription of physician orders and adherence to stop order policies. Periodically observes all residents' skin conditions and monitors weekly documentation of these conditions per facility policy. Make daily rounds and periodic rounds to observe and evaluate the residents' physical and emotional status, thereby ensuring continuing quality care. NJAC 8:39-27.1 (a)(e)