State Findings:
Based on observations, clinical record review and staff and resident interviews, it was determined that the facility failed to provide care consistent with professional standards of practice to accurately assess and identify skin impairments and implement measures to prevent the development of pressure sores, promote healing of existing pressure sores and prevent new pressure sores from developing for two residents (Resident 56 and 54) out of five sampled with pressure sores.
An observation of the resident’s wounds was conducted on January 15, 2020, at approximately 9:30 AM accompanied by the DON and Employee 10, RN. Observations, which were confirmed by the Director of Nursing at the time, revealed that the wounds were not consistent with the description in nursing progress notes or the skin alteration sheets. Observations revealed that the pressure areas were deep tissue injuries (a unique form of pressure ulcer. The National Pressure Ulcer Advisory Panel defines a deep tissue injury as A pressure-related injury to subcutaneous tissues under intact skin. Initially, these [MEDICAL CONDITION] have the appearance of a deep bruise) and were unstageable due to slough (dead white blood cells, [MEDICATION NAME], cellular debris and liquefied devitalized tissue) present in the wound beds. The Director of Nursing and Employee 10, RN Unit Manager, conducted skin assessments at this time in order to accurately document the measurements and description of the pressure areas observed.
Interview with Employee 8, nurse aide, on January 15, 2020 at 10:00 AM revealed that the facility had been aware of the appearance of Resident 56’s pressure sores, but did not accurately document their appearance in the clinical record and skin alteration records and also did not identify them as pressure sores, but other forms of skin damage such as abrasions.
Interview with the Director of Nursing on January 15, 2020 at approximately 2:00 PM confirmed that the measurements and description of the resident’s wounds observed that morning were not consistent with the facility’s skin alteration records. The DON verified that the facility was unable to demonstrate the implementation of necessary measures to prevent the development and worsening of multiple pressure areas.
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