SCOTTSDALE, AZ – HERITAGE COURT POST ACUTE OF SCOTTSDALE

Based on observation, clinical record reviews, staff interviews, facility documentation and policy and procedures, the facility failed to ensure that care and treatments were provided to 1 of 3 sampled residents (#4) who developed an unstageable pressure ulcer, and by failing to provide care and treatments for two additional pressure ulcers which were present upon admission. There were five residents in the facility who were identified as having pressure ulcers. The deficient practice could result in delayed wound healing and/or deterioration of wounds.

An interview was conducted with a Certified Nursing Assistant (staff #42) on (MONTH) 20, 2019 at 1:59 p.m. She stated that residents would be at risk for pressure ulcers if staff were not cleansing residents well after incontinence, if left in a wet brief, and if a resident stayed in the same position too long. She stated that residents are repositioned every two hours and receive indwelling catheter care at least one time each eight hour shift by the CNA’s. She stated that catheter tubing could cause pressure and staff could place a towel between the skin and catheter tubing and to make sure there is slack in the tubing between the stat Lock (indwelling urinary catheter stabilization device) and the insertion site. She stated that during catheter care, staff should lift the tubing when cleaning and visualize the skin beneath the tubing, and if she noticed any skin changes she would tell the nurse right away to come and assess the area. She stated that a resident should not develop a pressure ulcer under the indwelling urinary catheter tubing. Staff #42 said that she received in-services regarding residents with indwelling catheters and that staff were told to ensure that the skin was intact beneath the indwelling catheter tubing. She stated that during the training the wounds on resident #4’s thighs were presented to the CNA’s as pressure ulcers and were avoidable.