BROWNWOOD, TX-CROSS COUNTRY HEALTHCARE CENTER

Based on interview and record review, the facility failed to ensure that the resident was free from neglect for 1 of 3 residents (Resident #1) reviewed for neglect.
1. The facility failed to implement new wound treatment orders and provide wound care to Resident #1’s unstageable pressure ulcer to her right hip which had deteriorated to stage 4. Additionally, Resident #1 developed 3 other wounds in the following areas:
a) Stage 3 right internal aspect upper thigh
b) Unstageable left hip
c) Unstageable right posterior aspect of lower thigh
d) Unstageable left gluteal region.
2. The facility failed to ensure these multiple wounds on Resident #1 were identified, assessed, and treatment was provided to promote healing.
3. The facility failed to inform the physician of the Resident #1 pressure ulcers or obtained required orders to treat the resident’s wounds.
4. The facility failed to document that Resident #1 had a pressure ulcer.

Review of Resident #1’s admission MDS assessment, undated revealed the resident was always continent of bowel/bladder and required limited assistance with most ADLs and transfer. The assessment reflected the resident was not at risk of developing pressure ulcer and had no pressure ulcers at the time of the assessment.

During interview with LVNE on 10/15/21 at 11:08a.m, she was an agency nurse that took care of Resident #1 on 10/09/21. LVNE explained Resident #1 had multiple pressure ulcers which was in bad shape. LVNE was asked how did she know what to use to provide wound care without physician orders or treatment notes? She said she received verbal report from RN F and what the facility was using to dress the wounds. She was asked how many wounds did the Resident #1 have? LVNE stated she did not know and failed to document her treatment of [MEDICAL RECORD OR PHYSICIAN ORDER].

Interview with RNF on 10/15/21 at 1:44 p.m revealed she has been working for the facility for 5 years.  RNF said she was responsible and took care of Resident #1 on weekends. She explained Resident #1 had one pressure ulcers that she was aware until last week when she saw her, at which time Resident #1 had more wounds. When she asked CNAA, she said Resident #1 had always had the wounds. RNF proceeded to dress the wound. She was asked if she called the doctor when she discovered the new pressure ulcer. She said she did not. RHF stated she used facility standing wound treatment order. RNF was asked if she documented the multiple wounds and her treatment. She said she did not. RNF was asked to descript the facility protocol on admission of a resident. She explained on admission, the charge nurse looks at discharge information. The resident is assessed including detailed skin observations. The wound or pressure ulcers are documented. The charge nurse will call the doctor and received treatment instructions. He/she will follow the doctor’s order. RNF acknowledged the facility protocol was not followed for Resident #1 care and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] .

During interview with Director of Nursing on 10/15/21 at 10:42a.m she acknowledged the following on the care or lack thereof of Resident #1
1) She assessed the resident on admission
2) Stated the resident skin was assessed as normal
3) No documentation of Resident #1 weekly skin assessments
4) No physician orders for the pressure ulcer
5) No documentation of wound treatment provided to Resident #1 over 21 days after admission
6) Facility wound management section was blank for Resident #1
7) Staffs did not follow the facility policy in providing the necessary care and services to Resident #1 particularly pressure ulcer care
8) The physician was not aware of Resident #1’s pressure ulcer until he was notified on 10/11/21 that Resident #1 pressure ulcer may be infected. He ordered an antibiotic treatment with [MEDICATION(S)]
9) She failed to train agency nurses on the facility policy on wound care and documentation
10) No documentation of first transfer to the hospital on 9/14/21 and return on 9/16/21

 She stated, I dropped the ball.
She noted there no physician orders to provide the necessary care and services to Resident #1.

During interview with Physician Y on 10/14/21 at 2:25p.m, he said he was the primary for Resident #1. He explained he was not aware the resident had pressure ulcers.