LONGVIEW, TX – PINE TREE LODGE NURSING CENTER

Based on interview and record review, the facility failed to ensure necessary treatment and services, consistent with professional standards of practice, to promote healing and prevent new pressure injuries from developing was provided for 1 of 4 residents reviewed for pressure injuries. (Resident # 1)

The facility did not provide scheduled treatment for [REDACTED]. The facility did not complete 6 scheduled treatments between 1/5/21 and 1/15/21.

The facility did not obtain a dietary consult for Resident #1 when he developed a pressure injury according to their facility policy.

The facility did not identify and treat a pressure injury on Resident #1’s right heel.

This failure could place residents at risk for new development or worsening of existing pressure injuries, infection, pain, and decreased quality of life.

During an interview on 1/25/21 at 3:25 p.m., the nurse consultant said Resident #1’s worsening pressure ulcer should have been detected before it became unstageable on 1/12/21. The nurse consultant said if the same person had done the wound care on a daily basis they should have recognized the wound was getting worse. The nurse consultant said the charge nurses assigned to the resident had personal responsibility for the wound treatment, but the ADON and DON should have been checking to make sure the treatments were completed. The nurse consultant said the facility did not refer Resident #1 to a wound care specialist because he resided on the COVID-19 positive unit and the wound care doctor would not go to the unit. The nurse consultant said the facility did not ask for a tele-med visit. The nurse consultant said Resident #1 was not referred for a dietary consult for wound care or weight loss.