AURORA, CO-LIFE CARE CENTER OF AURORA

Based on interviews, record review, and facility policy review, it was determined the facility failed to consistently assess and document the status of a pressure ulcer in order to track healing progress and facilitate prompt identification of any potential deterioration for 1 (Resident #52) of 3 sampled residents reviewed for pressure ulcers.

Review of a care plan, dated as initiated 09/28/2022 and revised 10/12/2022, revealed the resident had a pressure ulcer to the sacrum (located on the lower back, just above the coccyx/tailbone). Interventions a pressure reducing mattress, treatment as ordered, and weekly skin checks. The care plan did not indicate there were any other areas of skin breakdown but did address that the resident was at risk for a break in skin integrity and had the potential for pressure ulcer development.

A review of a Progress Note, dated 11/22/2022 and signed by the Interim DON, revealed the resident was assessed by the wound doctor for a stage 3 pressure injury to the right buttock, an abscess to the left great toe, and a stage 4 pressure injury to the left second toe. The note indicated the wound doctor ordered treatments for the left second toe and the use of toe separators to separate the left great toe from the left second toe.

During an interview on 11/30/2022 at 10:20 AM, the Interim DON stated the facility did not have a wound nurse. She revealed there was a wound doctor who came to the facility every Tuesday and a wound team, consisting of the Interim DON and two unit managers, who would advise the nursing staff about possible treatments but would not necessarily look at the wounds.

During an interview on 11/30/2022 at 11:11 AM, the wound care doctor (WCD) stated he came to the facility weekly, and the DON would provide him with a spreadsheet of residents he needed to see, the location of the wound, and possible cause. The WCD further stated he used a tablet app that generated wound tracker forms. His process was to update the wound tracker form then email completed forms to the DON following the visit. For Resident #52, he did not see a wound on the second toe when he assessed an existing wound on the resident’s left great toe on 11/15/2022, but on 11/22/2022 when he assessed Resident #52’s existing great toe wound, he found the wound on the second toe, and it was a stage 4 wound. The WCD stated the nursing staff did not alert him of a wound on the second toe prior to his visit on 11/22/2022. The WCD stated the wound would have developed over approximately three days before becoming a stage 4 pressure injury, and the wound should have been found during the daily dressing changes on the left great toe.