Brookdale Galleria

Penalty

Inspection fine: $16,355

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to provide adequate supervision and prevent accidents when a cognitively impaired resident was able to leave the building unnoticed during the night and was later found on a public street. The resident was an older female admitted for rehabilitation after a cerebral infarction (stroke) and had a Brief Interview for Mental Status (BIMS) score of 7/15, indicating severe cognitive impairment. Her care plan identified an ADL self-care performance deficit related to weakness and deconditioning from a recent hospital stay, with interventions focused on encouraging participation in care, use of the call bell, explanation of procedures, and PT/OT evaluation and treatment. The care plan did not identify or address elopement risk or specific supervision needs related to her cognitive status. On the night of the incident, nursing documentation shows that at approximately 11:00 p.m. the resident was observed in bed sleeping and vital signs were taken without changes. Around 1:00–1:15 a.m., the RN making rounds discovered the resident was no longer in her bed, checked her bathroom and adjacent rooms, and did not find her. Security was alerted, and the RN searched the stairwell and pool area without locating the resident, then proceeded to the front of the building. A security guard reported that he had allowed a woman to exit the building around that time, believing she was homeless. Staff then searched outside and found the resident walking on a pedestrian walkway along the road to the right side of the building. She was returned to the facility, assessed with no injuries noted, and one-on-one supervision was initiated. Interviews and record reviews revealed multiple failures in supervision and identification that led to the elopement. The security guard stated he saw the resident in the swimming pool area, opened a locked gate for her when she could not open it, and escorted her out the front door without asking her name or any identifying questions, without checking for identification, and without notifying nursing staff. He reported assuming she was homeless based on her statement that she came through a back door used by homeless individuals and stated he did not see any identifying bracelets or clothing that would make him think she was a resident, although the family member reported the resident was wearing a fall-risk bracelet and a visible heart monitor. The facility had a pool area and dog park accessible from emergency exits and gates, and the resident was able to reach these areas and then the front of the building without being recognized or stopped by staff. The family member and speech therapist both described the resident as having significant cognitive and communication deficits, including difficulty understanding verbal instructions, needing repeated explanations and visual aids, and not consistently being oriented to person, place, or time, yet these deficits were not effectively incorporated into supervision practices that would have prevented her from leaving the facility unnoticed.

Removal Plan

• Instituted immediate monitoring of emergency exit doors leading outside to the pool and common areas by assigning a staff person at each door of egress; implemented a sign-in/sign-out sheet and prohibited resident/visitor/staff exit unless there is an emergency; ensured assigned staff are relieved for breaks/lunches with documentation on an assigned form.
• Implemented staff exterior walking rounds with documentation, including hourly rounds in the dog park and pool areas; verified dog park gate and pool gate are secured with staff initials.
• Implemented walkie-talkie protocol: charge nurses check out walkie talkies at the beginning of each shift and return them at the end to enhance communication with security.
• Re-educated staff on emergency exit and fire door usage: staff must not use these doors unless there is an emergency and must investigate each time an alarm sounds.
• Re-educated staff on elopement/missing resident procedures: alert staff by calling a Code Yellow, complete skills check quiz for each employee, and ensure elopement binders are located on the 1st and 2nd floor nurses' stations and at the front desk.
• Provided in-service on abuse and neglect (definitions, types, reporting) and identified the abuse coordinator.
• Provided instant in-service on unfamiliar person protocol to remind staff of obligations to identify all persons on the property.
• Completed elopement risk assessments on all residents in the facility.
• Conducted impromptu QAPI meetings addressing resident elopement, binder use, behavior monitoring, swimming pool concerns, and staff assignment at fire door/egress monitoring.
• Began facility-wide education on emergency exit usage and alarm investigation for all departments; ensured staff not in-serviced would be in-serviced prior to their next shift with documentation.
• Completed facility-wide education on resident elopement/missing resident search procedure, proper notification, resident assessments, and resident monitoring; ensured staff not reeducated would be reeducated before their next shift; began elopement skills testing with documentation.
• Began facility-wide education on abuse and neglect (definitions, abuse coordinator, types, importance of timely notification); ensured staff not reeducated would be reeducated before their next shift; implemented abuse/neglect skills testing once per shift.
• Re-educated security/concierge staff on initial contact and verification of a wandering resident: ask identifying questions, check for identifying markers, call nurses’ stations to verify, and refer to the elopement binder; required retraining prior to returning to duty with documentation.
• Implemented additional communication protocol between nursing and front desk/security using walkie talkies: devices located/charged at concierge desk; at least one security associate and one direct care associate on each floor carry walkie talkies; one issued per floor with sign-out and return at end of shift; education completed prior to next shift with documentation.
• Educated night shift staff on security protocol, unfamiliar persons protocol, and abuse and neglect.
• Provided immediate re-education to all security and concierge staff on safety monitoring protocols: hourly walking rounds in pool and dog park areas, continuous monitoring of pool area via security cameras with feed visible at all times, prompt reporting of adverse findings to leadership, and accurate/timely documentation; documented on an in-service sheet.
• Re-educated the Healthcare Administrator on the facility abuse policy and elopement policy.
• Regional Director of Clinical Services educated the Executive Director and Healthcare Administrator on missing resident policy and swimming pool/spa policy.
• Provided ongoing oversight by the Executive Director and Healthcare Administrator to ensure adherence to protocols, with prompt corrective action and additional training for deviations.
• Placed a staff member at the emergency exit door between the dog park and pool area to redirect anyone attempting to exit unless there is an active emergency; maintained coverage until the gate could be reassessed and an appropriate locking mechanism installed.
• Scheduled a meeting with an approved technology company with the Administrator, Director of Maintenance, and Executive Director to assess and implement an appropriate locking mechanism for the gate between the dog park and pool area.
• Required security to complete hourly walking rounds of the pool and dog park areas; document and report any adverse findings to the Director of Resident Services, Executive Director, and Healthcare Administrator.
• Reviewed the pool area policy and reaffirmed that access is restricted to Independent Living residents and skilled care residents are not allowed access.
• Conducted monitoring observations and interviews across all shifts to verify in-service training completion and staff competencies/understanding, including reenactment drills and knowledge checks.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that a resident with a diagnosis of dysphagia, as identified by a speech therapy evaluation, received appropriate orders for crushed medications. Despite the speech therapy evaluation documenting the need for crushed medications due to swallowing difficulties, there was no corresponding physician order in place from the time of the evaluation until nearly two months later. The resident's care plan did not include interventions for dysphagia or the need for crushed medications, and the medical record lacked a documented diagnosis of dysphagia during this period. Observations and interviews revealed that the resident was receiving crushed medications without a current physician order. Multiple nursing staff members confirmed that medications were being crushed and administered to the resident, but they were unaware of the specific reason or lacked knowledge of the resident's swallowing issues. Staff interviews consistently indicated that an order is required before crushing medications, and the absence of such an order was acknowledged as a deviation from facility policy and professional standards of practice. The speech pathologist confirmed the resident's need for crushed medications and swallowing precautions, stating that these requirements should be reflected in the care plan and supported by physician orders. The administrator and nursing staff acknowledged that the lack of orders for crushed medications could place residents at risk, and that the facility's policy requires medications to be crushed only with appropriate orders and documentation. The deficiency was identified through record review, staff interviews, and direct observation.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that assessments accurately reflected a resident's status, specifically regarding a diagnosis of dysphagia and the need for a modified diet and crushed medications. The resident, an older adult male with multiple diagnoses including kidney failure, dementia, Parkinson's disease, stroke, and a history of stomach cancer, did not have dysphagia documented on his face sheet, Minimum Data Set (MDS), or care plan, despite evidence from a speech therapy evaluation indicating the presence of dysphagia and the need for swallowing precautions, a modified diet, and crushed medications. Review of the resident's records showed that the care plan and MDS did not include a diagnosis of dysphagia or interventions related to swallowing difficulties or medication administration. The speech therapy evaluation documented specific swallowing impairments and recommended interventions, but these were not reflected in the resident's official diagnoses or care planning documents. Interviews with facility staff, including the speech pathologist and MDS nurse, confirmed that the resident required these interventions and that the diagnosis should have been included in the resident's records and care plan. The MDS nurse acknowledged that the omission of the dysphagia diagnosis and related care plan interventions was an error and that the resident's assessments and care plan were inaccurate at the time of the survey. The facility's policy on certifying the accuracy of resident assessments did not specifically address the accuracy of assessments, and the responsible staff confirmed that the resident's records were not updated to reflect the dysphagia diagnosis and required interventions until after the surveyor identified the discrepancy.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with a diagnosis of dysphagia, as identified through a speech therapy evaluation. Despite the resident's medical history, which included kidney failure, difficulty walking, dementia, Parkinson's disease, stroke, and a history of stomach cancer, there was no documented diagnosis of dysphagia on the face sheet or in the Minimum Data Set (MDS). The resident's care plan did not address dysphagia or the need for crushed medications, even though the speech therapy assessment indicated the resident required a modified diet, swallowing precautions, and crushed medications due to difficulty swallowing. Observations and interviews revealed that the resident reported receiving crushed medications for swallowing difficulties but noted inconsistency in this practice. The speech pathologist confirmed the resident was on swallowing precautions and required a soft diet, thin liquids, alternating bites, crushed medications, and upright positioning during meals. The speech pathologist also stated that the resident's dysphagia and need for crushed medications should have been included in the care plan, and that it was nursing's responsibility to ensure this was addressed. The nurse practitioner acknowledged the resident's swallowing difficulties but deferred to speech therapy for medication orders. The MDS nurse, responsible for updating diagnoses and care plans, confirmed that the resident's dysphagia was documented in therapy notes but not reflected in the face sheet, MDS, or care plan at the time of the survey. The nurse stated that this omission could result in the resident not receiving proper care, as the care plan did not accurately reflect the resident's needs for swallowing precautions and medication administration. The facility's policy required comprehensive care plans to include measurable objectives and timeframes based on comprehensive assessments, which was not followed in this case.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency occurred when a resident with respiratory failure, hypoxia, pneumonia, COPD, and heart failure did not receive appropriate respiratory care as required by professional standards and the resident's care plan. The resident was ordered to receive oxygen therapy at 2 liters per minute via nasal cannula, with humidification and weekly changes of oxygen tubing and water for infection control. Documentation indicated that staff signed off on changing the tubing and water, but on observation, the water bottle attached to the oxygen concentrator was found empty and dated from ten days prior, while the resident was still receiving oxygen. Interviews with nursing staff revealed that they were expected to monitor oxygen settings, tubing, and water levels each shift, and to document these checks. However, staff did not notice the water bottle was empty or that the date was outdated. Some staff believed that changing the water was part of the tubing change task, and that documentation of tubing change included water change, but there was inconsistency in actual practice and awareness. Staff also reported that the water was supposed to be changed weekly, but if it emptied sooner, it could be changed as needed, which did not occur in this instance. The facility's policy required humidifiers to be checked and changed per manufacturer recommendations, and for nurses to monitor and record the resident's response to oxygen therapy. Despite these policies, the lack of water in the humidifier while the resident was receiving oxygen was not identified or addressed by staff, resulting in a failure to provide safe and appropriate respiratory care as ordered and per professional standards.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency occurred when a nurse inaccurately documented the completion of changing a resident's oxygen tubing and water in the medical record, despite not having performed the task. The resident, an elderly female with diagnoses including respiratory failure, pneumonia, COPD, and heart failure, was receiving oxygen therapy as ordered. Documentation in the Treatment Administration Record (TAR) indicated that the oxygen tubing was changed on a specific date, but an observation revealed that the water bottle attached to the oxygen concentrator was empty and had not been changed since a prior date. Interviews with nursing staff and the interim Director of Nursing confirmed that the nurse's signature on the MAR was intended to indicate both the tubing and water had been changed, which was not the case. Facility policy required that all services provided to residents be documented in the medical record, and that oxygen humidifiers be checked and changed as needed. However, the policy did not specifically address the accuracy of documentation. The failure to accurately document the completion of required care tasks resulted in incomplete and inaccurate medical records for the resident.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that the daily staffing postings were complete and readily accessible for review on both the 1st and 2nd floors. Observations revealed that the Daily Associate Postings were hung on clipboards on the corner walls across from the nursing stations, located at the end of a T-shaped hallway, making them not easily visible or accessible to all residents, staff, and visitors. Additionally, the postings did not include the facility name on certain days, and on other days, the resident census was omitted from the postings. Interviews with the Staffing Coordinator indicated a lack of knowledge regarding CMS requirements for the Daily Associate Posting, as well as an absence of training prior to assuming responsibility for creating and posting the schedules. The Staffing Coordinator admitted to using a template without understanding all required elements and acknowledged that the postings' locations were not prominent or visible to everyone entering the facility. The Administrator confirmed that the postings were not in a location visible to all and that the Staffing Coordinator had not received appropriate training. Record reviews showed that the blank Daily Associate Posting forms did not have the facility name, and the postings observed in the open sitting areas before the resident room hallways included the facility name but omitted the resident census. The facility's policy required that the postings include the facility name, current date, resident census, and staffing for each shift, and that they be displayed in a prominent, accessible location. These requirements were not met during the survey period.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A licensed vocational nurse (LVN) failed to provide pharmaceutical services in accordance with facility policy by not remaining in the room to observe a resident taking prescribed oral medications. The LVN entered the resident's room with a cup containing pills, which was handed to the resident's family member, who then administered the medications to the resident one by one. While the family member was still administering the last two pills, the LVN left the room to return to the medication cart, without confirming that all medications had been taken. The LVN later acknowledged that she should have stayed in the room to ensure all medications were administered and that the metformin pill was still in the cup when she left. Interviews with the unit manager and the director of nursing (DON) confirmed that nurses are required to follow the five rights of medication administration and must observe residents taking their medications to completion. The facility's medication administration policy also specifies that staff must observe the client taking the medication. The resident involved had multiple diagnoses, including spinal stenosis, hypertension, diabetes mellitus, and anxiety disorder. The care plan did not address medication administration, and the resident's BIMS score was not completed at the time of the incident.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Surveyors identified that the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. During an observation of the kitchen, multiple food items were found in the walk-in refrigerator and pantry that were past their use by dates, including bay leaves, pork, beef, beef tips, brisket, and chocolate fudge icing. These items had use by dates ranging from several days to over a month prior to the observation. Staff interviews confirmed that all kitchen personnel, including dietary management and administration, had received training on proper food storage, labeling, and the requirement to discard expired foods. Staff consistently stated that expired foods should be thrown away immediately and acknowledged the potential for illness if expired foods were consumed. A review of the facility's policy on labeling, safety, and sanitization indicated that all food items must be labeled with received dates and that prepared items must be labeled with preparation and discard dates, with specific timeframes for discarding leftovers and hazardous foods. Supervisors are responsible for ensuring that no food items are kept past their expiration or use by dates. Despite these policies and staff training, expired food items were still present in the kitchen, indicating a failure to follow established procedures for food safety.

Penalty

Inspection fine: $10,033

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide necessary treatment and services to a resident, leading to the development of a Stage IV pressure ulcer. Upon admission, the resident had a healed area on the sacrum with a scab and pink skin, which was not properly identified or documented by the nursing staff. This oversight resulted in the area developing into a pressure ulcer within approximately 12 days of admission. The resident, who was non-verbal and required substantial assistance for mobility, was initially placed on a regular mattress and not repositioned frequently enough, contributing to the skin breakdown. The resident's care plan included interventions such as dietary supplementation, a low air loss mattress, and assistance with turning and repositioning. However, these measures were not effectively implemented from the start. The CNA responsible for the resident admitted to not repositioning the resident frequently enough and was unaware of the specific care requirements due to a lack of communication from the nursing staff. The resident's condition was further complicated by issues with hydration, nutrition, and immobility following a fracture, which were not adequately addressed in a timely manner. Interviews with facility staff revealed a lack of consistent documentation and communication regarding the resident's skin condition and care needs. The DON acknowledged that the initial interventions were ineffective and that the air mattress was introduced later as an additional measure. The wound physician noted that the resident had a pre-existing wound, which increased the risk of reopening, and emphasized the importance of frequent repositioning and appropriate mattress use. Despite these insights, the facility's failure to implement timely and effective interventions led to the resident's pressure ulcer worsening to a Stage IV.

Penalty

Inspection fine: $10,033

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of RN B during wound care for a resident. The resident, an elderly female with a history of a left femur fracture, hypertension, and the presence of a left artificial hip joint, was admitted to the facility with skin integrity issues, including a blister and pressure injury. During an observation, RN B did not perform hand hygiene after removing the resident's soiled dressing and before applying a new dressing, which is a critical step in preventing infection. RN B was observed conducting wound care without washing or sanitizing her hands or changing gloves after handling the resident's soiled dressing. Despite having received recent training in wound care and infection control, RN B neglected to follow the facility's established procedures, which require hand hygiene after removing soiled dressings and before applying new ones. This lapse in protocol was acknowledged by RN B, who admitted the importance of hand hygiene in protecting residents from infection. Interviews with the Unit Manager LVN P and the Director of Nursing (DON) confirmed that RN B should have performed hand hygiene as per the facility's policies. The facility's infection prevention and control program, as well as its hand hygiene and wound care procedures, emphasize the importance of hand hygiene in preventing the spread of infections. Despite these established guidelines, the failure to adhere to them during the observed wound care session represents a deficiency in the facility's infection control practices.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that a resident's assessment was updated at least once every three months. Specifically, Resident #4's quarterly MDS assessment, which was due for completion by 4/10/2024, was not completed by the time of the record review on 04/24/2024. This oversight was identified during an interview with the MDS Nurse, who admitted to forgetting to complete the assessment. The resident, a [AGE] year-old female diagnosed with vascular dementia, Parkinson's disease, and protein calorie malnutrition, had her last comprehensive MDS dated 01/09/2024. The MDS Nurse stated that assessments are typically completed within 14 days, with the DON having an additional 7 days to sign off and transmit the MDS to CMS. However, the MDS Nurse was unaware that she had missed the quarterly assessment for Resident #4. The DON confirmed that while she signs off on MDS assessments, she does not audit the MDS Nurse's work. The failure to complete the MDS on time could affect billing and updates in resident care plans, as per the RAI Manual guidelines.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to administer the medication Esomeprazole to a resident on three consecutive days as ordered by the physician. The resident, who has a history of GERD and other digestive system diseases, did not receive her prescribed doses on 04/21/2024, 04/22/2024, and 04/23/2024. The medication was noted as pending in the nursing progress notes, and the pharmacy was contacted, but the medication was not available in the Omnicell system. The resident reported experiencing indigestion due to the missed doses. Interviews with the nursing staff revealed that the nurses were responsible for reordering medications when only 3-4 doses were left. However, the medication was not reordered in time, leading to the missed doses. The Director of Nursing (DON) confirmed that the medication should have been reordered on 04/19/2024 or 04/20/2024. The DON also stated that the medication could have been picked up at a local pharmacy but required a higher dose, which needed to be ordered. The facility's policy on reordering medications did not specify when to place reorders when medications run low. The policy allowed for reorders to be written, submitted verbally, faxed, or electronically. The failure to administer the medication as ordered and the lack of a clear policy on reordering medications contributed to the deficiency, potentially placing the resident at risk of inadequate therapeutic outcomes and discomfort.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that the medication error rate was not five percent or greater, resulting in a medication error rate of 7%. This was based on two errors out of 28 opportunities, involving two residents. One error involved an LVN failing to administer Esomeprazole Magnesium delayed release 40mg to a resident with GERD and a history of digestive system disease because the medication was out of stock. The LVN did not know why the medication was unavailable and had to contact the pharmacy, resulting in the medication being put on hold. The resident's care plan specifically required the administration of medications as ordered, which was not followed in this instance. The second error involved another LVN administering Vitamin B12 with Folate instead of the physician-ordered Vitamin B12 without folate to a resident with cardiovascular issues and a pressure ulcer. The LVN was unaware that the Vitamin B12 contained folate and administered it along with a separate folic acid tablet. The LVN later acknowledged the mistake and indicated that she would check for the correct medication and contact the NP for a possible order change. The facility's policy required verification of the correct medication, dose, and route each time a medication is administered, which was not adhered to in this case.

Penalty

Inspection fine: $40,203

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to immediately consult with the resident's physician when there was a significant change in the resident's physical status. Specifically, the staff identified a sacral wound on a resident but failed to perform and document a wound assessment, notify the physician, and obtain wound care orders until four days later. This delay in care led to the resident's condition worsening, resulting in an infected decubitus ulcer that required hospitalization and surgical intervention. The resident, who was admitted with multiple diagnoses including a fracture, morbid obesity, and type 2 diabetes, was found to have a sacral wound on 2/16/2024. Despite the presence of the wound, nursing notes from 2/16/2024 to 2/19/2024 did not document any new or worsening skin conditions. It was not until 2/20/2024 that the wound was assessed, and appropriate wound care orders were obtained. Interviews with various staff members revealed a lack of communication and responsibility in reporting and managing the wound. The failure to notify the physician and obtain timely wound care orders resulted in the resident being taken to the hospital by a family member due to the severity of the wound. The hospital records indicated that the resident had an infected decubitus ulcer with significant necrotic tissue, requiring incision and drainage. The facility's inaction and poor communication among staff members contributed to the resident's deteriorating condition and subsequent hospitalization.

Penalty

Inspection fine: $40,203

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that a resident with a sacral wound received necessary treatment and services consistent with professional standards of practice. The resident was identified with a sacral wound on 2/16/2024, but the facility staff did not perform and document a wound assessment, notify the physician, or obtain wound care orders until four days later on 2/20/2024. The wound care physician assessed the resident on 2/22/2024 and diagnosed the resident with an unstageable sacrum full-thickness pressure wound with a surface area of 129.72 cm². During this period, facility staff were performing dressing changes without a physician's order, which contributed to the deterioration of the wound. Interviews with various staff members revealed a lack of communication and responsibility regarding the wound care of the resident. The Assistant Director of Clinical Services acknowledged that there was no notification to the physician and no orders for wound care for two days. LVN A admitted to assuming that the weekend supervisor would manage the wound care, while CNA K reported the wound to LVN B but did not see any immediate action taken. CNA L and CNA M also observed the wound and reported it to different nurses, but no timely intervention was made. The lack of proper documentation and communication among the staff led to the resident's wound worsening and eventually becoming infected. The resident's medical history included morbid obesity, type 2 diabetes, and a urinary tract infection, which made her more susceptible to pressure ulcers. Despite the resident's high risk for pressure injuries, the facility staff failed to reposition her adequately and did not follow the care plan interventions. The resident's condition deteriorated to the point where she was removed from the facility by a family member and taken to the hospital, where she was diagnosed with an infected decubitus ulcer and underwent surgical intervention. The facility's failure to provide timely and appropriate wound care resulted in significant harm to the resident.