Surveyors found that the facility failed to follow professional standards and internal policies for pressure ulcer prevention and treatment for two residents. One resident with dementia and a right femur fracture, weighing about 100 lbs, was observed on a low-air-loss mattress set to 220 lbs, despite a physician order for a specialty mattress and a policy requiring mattress settings to match resident weight and be verified each shift; the care plan for skin integrity risk did not list the low-air-loss mattress as an intervention. Another resident with multiple chronic conditions had a full-thickness right lower leg skin tear with physician-ordered daily and PRN wound care, but the eTAR showed no nurse signatures for completion of the ordered treatments over six consecutive days, contrary to the facility’s wound care policy requiring treatments to be completed and documented.
A resident with a Stage 3 sacral/coccyx pressure ulcer and multiple chronic conditions, including quadriplegia and DM2, had daily wound care that was not documented on the eTAR for one day. The surveyor also found that a wound care consultant recommended changing the treatment to collagen powder, but there was no contemporaneous documentation that nursing notified the physician or that the physician reviewed, accepted, or declined the recommendation, and the original Triad paste order remained in place.
Pressure ulcer treatment, documentation, and hand hygiene failures: A resident with severe cognitive impairment and facility-acquired heel and buttock pressure injuries had missing eTAR signatures for ordered wound care, no timely CP for the heel wound, and no CP for the buttock wound. During observed wound care, an LPN used a handwashing method that did not match policy, and a CNA returned room items to the treatment cart without disinfecting them. Staff confirmed the documentation gaps and improper hand hygiene process.
Air mattress settings were not matched to resident weight for multiple residents with pressure injury risk, impaired mobility, incontinence, and cognitive impairment. Surveyors observed mattresses set at incorrect weights, including settings far above or below the residents’ documented weights, and one resident had no active air mattress order even though the mattress remained in use. Staff confirmed the mattresses were intended for pressure prevention and that the setting should correspond to the resident’s weight.
A resident with a history of skin breakdown and multiple medical conditions did not receive a physician-recommended pressure ulcer treatment for three days after the recommendation was made. The facility delayed implementing the new wound care regimen, waiting for an official report before updating the treatment orders, despite policy requiring prompt adherence to physician orders.
Two residents with significant cognitive and physical impairments did not consistently receive or have documented wound care as ordered by their physicians, as shown by multiple blank entries in the Treatment Administration Records for various wound treatments and assessments. The DON confirmed that nursing staff were responsible for implementing and documenting these orders, but the facility's own documentation policy was not followed.
A resident with severe cognitive impairment and arterial ulcers did not receive prescribed wound dressing changes as ordered, and nursing staff failed to document the resident's refusals or notify the physician. The wound dressing was not changed according to the schedule, and the medical record did not accurately reflect the missed treatments or refusals, contrary to facility policy.
A resident with paraplegia and other medical conditions developed a stage 2 pressure ulcer, but there was no evidence that a physician's order for wound care was entered or that wound care was provided and documented for two days after the wound was discovered. Interviews confirmed that wound care orders were not initiated or documented as required by facility policy.
A resident with multiple comorbidities and incontinence was not given a complete and accurate skin assessment upon admission, resulting in missed documentation of excoriation and edema. The initial assessment failed to identify skin impairment, and wound care orders were delayed until a subsequent assessment by an LPN. Required incident reporting and documentation were not completed as per facility policy.
The facility failed to provide wound care treatments as ordered by physicians for three residents with skin impairments. In each case, the treatment administration record was signed as if wound care was completed, but direct observation and record review showed that dressings were not changed as required. The DON confirmed that signing the TAR should indicate completion of care, but this was not consistently done.
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