COMMERCE CITY, CO- IRONDALE POST ACUTE

Based on observations, record review and staff interviews, the facility failed to provide treatment and care in accordance with professional standards of practice for for two (#5 and #9) of four residents out of 11 sample residents.

Specifically, the facility failed to:
-Ensure skin assessments were accurately documented for Resident #5 and Resident #9; and,
-Ensure accurate wound care physician orders were in place for Resident #9.

Review of Resident #5’s electronic medical record (EMR) revealed the resident had the following skin issues:
-A diabetic ulcer to her right lateral ankle was discovered by an outside community provider on 12/1/22;
-A right heel deep tissue injury was discovered by an outside community provider on 12/8/22;
-A lateral right foot wound was discovered at the facility on 12/17/22;
-A medial right foot wound was discovered at the facility on 12/17/22; and,
-A stage 2 pressure injury was discovered upon the resident’s readmission to the facility following a hospital stay on 1/4/23.

Review of Resident #5’s weekly skin assessments, completed by night shift nurses, revealed the following documentation in pertinent part:

On 12/1/22, a nurse documented No new skin issues noted. Turgor (the degree of elasticity of the skin which is used clinically to assess for dehydration) is within normal limits and skin is warm and dry.

–The assessment did not document the diabetic ulcer to the resident’s right lateral ankle, which was
discovered later that day at an outside community provider appointment.

On 12/8/22, a nurse documented Resident continues with a diabetic wound to the left foot. Wound dressing clean, dry, and intact. Protective boot in place.

–The assessment did not document the right heel deep tissue injury, which was discovered later that day at an outside community provider appointment.

–The assessment documented the diabetic wound was on the left foot, despite the wound being on Resident #5’s right foot.

On 12/15/22, a nurse documented Skin intact.

-The assessment did not document Resident #5’s right ankle diabetic ulcer or the resident’s right heel deep tissue injury.

On 12/22/22, a nurse documented Resident continues with a diabetic wound to the left foot, Wound dressing changed as needed (PRN), skin prep applied to both heels. Protective boot in place.

-The assessment did not document Resident #5’s right heel wound or the right lateral foot and right medial foot wounds which were discovered on 12/17/22.

–The assessment documented the diabetic wound was on the left foot, despite the wound being on the resident’s right foot.

On 12/29/22, a nurse documented Resident continues with a diabetic wound to the left foot, Wound dressing clean, dry, and intact. Protective boot in place.

-The assessment did not document Resident #5’s right heel, right lateral foot, and right medial foot wounds.

-The assessment documented the diabetic wound was on the left foot, despite the wound being on the resident’s right foot.

On 1/5/23, a nurse documented Resident readmitted to facility 1/4/2023. Resident continues with a wound to the right foot. Dressing clean, dry, intact and bunny boot in place. Resident observed with bruises to both hands.

-The assessment did not document Resident #5’s documented only one wound to the right foot despite the resident having four wounds to the right foot.

-The assessment did not document the stage 2 pressure wound that was noted on 1/4/23 upon the resident’s readmission to the facility.

The DON was interviewed on 3/6/23 at 11:19 a.m. The DON said skin assessments were completed weekly by the scheduled nurse on the cart or a nurse manager. She said weekly skin assessments should be a complete head to toe assessment of the resident’s skin. She said skin assessments were important because a resident’s skin could break down easily if it was not monitored closely. The DON said the nurse should document the color of the skin, temperature of the skin, and whether or not the skin was intact or wounds were present. She said if a resident had wounds, the nurse should specify the location of the wounds, and whether or not the resident was being followed by the wound care team. She said if a wound dressing change was not scheduled to occur on the day of the resident’s weekly skin assessment the nurse should document that the wound dressing was intact.

The DON said all weekly skin assessments should be thorough and accurate. She said it was important for skin assessments to be accurate in order to monitor the resident for new wounds and to monitor for any further changes to the resident’s existing wounds. The DON said the nurses who conducted the skin assessments on Resident #5 on 12/1/22 and 12/8/22 should have identified and documented the wounds to the resident’s right lateral ankle and right heel prior to the wounds being discovered at the resident’s outside community provider appointments. She said the weekly skin assessments conducted on 12/15/22, 12/22/22, 12/29/22, and 1/5/23 were all documented inaccurately as they did not include all of the resident’s wounds.

The DON said the weekly skin assessments on 12/8/22, 12/22/22, and 12/29/22 were additionally
documented inaccurately because the nurse documented Resident #5’s diabetic wound was on her left foot instead of the right foot.

Resident #9

Resident #9’s weekly skin assessment completed on 3/3/23 documented in pertinent part, Skin clean, warm, dry, intact. Continues with orders for right heel skin prep status post tissue injury. Steri strips to right wrist.

–The assessment documented the pressure wound was on the resident’s right heel despite the wound being on the resident’s left heel.

Review of Resident #9’s March 2023 CPO revealed the resident had a physician’s order to cleanse the right heel with wound cleanser and apply foam dressing. Change two times a week and if soiled.

The order had a start date of 2/23/23 and was discontinued on 3/2/23

-The order specified the wound treatment order was for the resident’s right heel despite the wound being on the resident’s left heel.

Further review of Resident #9’s March 2023 CPO revealed a new physician’s order was obtained on 3/2/23 to cleanse the left heel pressure injury with wound cleanser, pat dry, and apply skin prep every day shift for wound care.

The DON was interviewed on 3/6/23 at 1:00 p.m. The DON said Resident #9’s 3/3/23 weekly skin
assessment was documented inaccurately. She said the assessment documented the resident’s wound was to her right heel, however the resident only had one wound which was on her left heel. 

The DON said Resident #9’s initial physician orders for wound care were not correct. She said the orders should have been for wound care to the left heel and not the right heel.