CHATTANOOGA, TN – WOODLAND TERRACE CARE AND REHAB

Based on facility policy review, medical record review, and interview, the facility failed to complete weekly monitoring and documentation of pressure ulcers and failed to provide physician ordered wound treatment for 1 resident (Resident #6) of 3 residents reviewed for pressure ulcers. The facility’s failure to monitor and provide treatment resulted in worsening of a pressure ulcer and Harm for Resident #6.

During a phone interview with the wound care clinic Nurse Practitioner (NP #2) on 2/25/2020 at 1:43 PM, NP #2 stated the resident had been seen in the clinic on 2/24/2020 with the wound on the right calf measuring 18.5 cm by 4.7 cm by 0.6 cm. NP #2 also stated on 12/31/2019, the clinic changed the dressing to the resident’s right calf and the nursing home staff was not to change the dressing until the resident was seen again at the clinic on 1/6/2020. After the nursing home had been unable to provide the Sorbact for 2 weeks, the clinic took over the dressing changes on 1/6/2020. The wound on the right calf had worsened due to the . burden of infection . in the wound. NP #2 stated the treatment needed to be provided 3 times weekly and the clinic was unable to see the resident 3 times per week. The facility’s inability to provide the ordered wound care dressing and change it 3 times weekly had contributed to the continuing infection and worsening of the wound.

During an interview on 2/26/2020 at 3:05 PM, the Director of Nursing confirmed the facility’s nursing staff did not complete weekly monitoring, measuring, and documentation for Resident #6’s wounds.