GLADEWATER, TX- LEGEND OAKS HEALTHCARE AND REHABILITATION CENTER G

Based on observation, interview, and record review the facility failed to ensure that residents with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 of 5 residents reviewed for pressure ulcers. (Resident #52)

*The facility failed to prevent the sacral wound from deterioration from a Stage 2 to a Stage 4 (over a 7-day period) of time.

*The facility failed to notify the physician of the wound decline between the visits on 10/04/22 and 10/11/22.

*The facility failed to obtain #52’s recommended lab orders (WBC, ESR, and CRP) from the wound care consultant on 11/01/22.

*The facility failed to ensure Resident #52’s low air loss mattress was functioning for 5 hours and 47 minutes on 11/06/22 from 9:15 a.m. to 3:02 p.m.

*The facility failed to provide treatment for Resident #52’s sacral wound for 4 days after admission starting on 08/30/22.

*The facility failed to provide #52’s wound care consultant evaluation for the sacral wound, indicated on 08/26/22 admission assessment until 9/27/22.

An Immediate Jeopardy (IJ) situation was identified on 11/07/22 at 4:40 p.m. While the IJ was removed on 11/08/22, the facility remained out of compliance at the severity of actual harm that is not immediate jeopardy with a scope identified as isolated due to the facility’s need to evaluate the effectiveness of the corrective systems. These failures placed residents with skin breakdown at risk of pain, worsening of wounds, wound infection, emotional distress, harm, or even death.

The additional documentation indicated Resident #52 had non-blanchable open area to the sacrum that was to be evaluated by the wound consultant. The admission record indicated Resident #52 was not provided an alternating air mattress, or a pressure re-distributing overlay mattress.

The admission assessment indicated Resident #52 did not have a pressure re-distributing mattress
but had an alternating air mattress. The general skin condition of Resident #52 was indicated to be normal and warm. The skin integrity indicated she had moisture associated skin damage on her buttocks but no pressure ulcers. 

Record review of a skin evaluation dated 09/27/22 indicated Resident #52 had MASD (moisture associated skin damage) to her buttocks completed by the treatment nurse . The note did not reflect a pressure injury.

Record review of an Initial Wound Evaluation and Management Summary (documented by the wound care consulting physician) dated 9/27/22 indicated Resident #52 had a Stage 2 pressure ulcer to the sacrum for at least 1 day duration.

Record review of a facility wound care report dated October 2022 indicated Resident #52 had a pressure ulcer to her sacrum (a shield shaped bony structure located at the base of the lumbar vertebrae and that was connected to the pelvis). The facility wound report indicated Resident #52’s pressure wound was obtained in-house on 9/27/22. The wound stage was classified as unstageable due to slough and eschar. Resident #52 was high risk due to the results of the last Braden score completed on 09/12/22.

Record review of a Wound Evaluation and Management Summary dated 10/04/22 indicated Resident #52 had a stage 2 pressure ulcer to her sacrum for at least 7 days. The note indicated the wound had moderate serous exudate.

Record review of a Wound Evaluation and Management Summary dated 10/11/22 indicated Resident #52 now had an unstageable wound due to necrosis (dead) tissue to her sacrum. The note indicated there was moderate serous exudate and was now a full thickness wound (tissue loss of the epidermis and dermis). The note indicated Resident #52’s wound measured 6 cm x 9.5 cm x 1 cm. The note indicated the wound had 40% slough, 50% granulation tissue, and 10% skin with the deteriorated wound status. The wound was surgically debrided (removal of dead tissue with a blade) devitalized tissue including slough, biofilm, and non-viable tissue at a depth of 1 cm.

Record review of the progress notes from 10/04/22 through 10/11/22 did not reflect a decline in Resident #52’s sacral wound from a Stage 2 to a Stage 4 during this time nor any documentation of the notification of her physician or responsible party.

Record review of a nurse practitioner no te dated 10/31/22 at 9:00 a.m., indicated Resident #52 was currently being treated for a sacral pressure ulcer stage 4 (the most severe form of a bedsore, a deep wound reaching the muscles, ligaments, or bones. Often cause extreme pain infection, invasive surgeries, or even death).

Record review of the Resident #52’s laboratory results did not indicate laboratory results for the CRP, WBC, and ESR recommended by the wound care physician on 11/01/22. During an interview on 11/07/22 at 12:38 p.m., the DON indicated Resident #52’s labs ordered on 11/01/22 was not completed because they were only suggested. The DON indicated she was unsure why the wound
culture was obtained and not the laboratory levels.

During an observation on 11/06/22 at 9:15 a.m., Resident #52’s low air loss mattress cord was not plugged in to the electrical outlet. The mattress cord was lying on the floor underneath her bed. The lights on the monitoring box were not on.

During an observation and interview on 11/07/22 at 9:16 a.m. to 9:49 a.m., the treatment nurse performed wound care for Resident #52’s Stage 4 sacral wound. The treatment nurse removed the top dressing and revealed a large and deep sacral wound with necrotic (dead) tissue at the noon to 3’oclock portion of the wound. The dressing was saturated in a copious amount of serosanguineous (blood-tinged drainage), and the wound was odorous. The treatment nurse indicated he was assisted by the staffing coordinator because she had a stronger stomach and could handle the odor. During the wound care Resident #52 began grimacing, groaning, and moving her face to the right imbedding her face in her pillow. Resident #52 was encouraged by the staffing coordinator to squeeze her hand. The staffing coordinator indicated Resident #52 was displaying pain. The staffing coordinator indicated Resident #52 displayed this behavior each time during the actual wound care procedure. The treatment nurse indicated Resident #52 was medicated earlier
this morning. The treatment nurse indicated he had even mentioned to the family about hospice care to have more effective pain management. During the wound care neither the treatment nurse nor the staffing coordinator stopped the wound care process to ensure adequate pain relief was achieved prior to finishing the treatment. Resident #52 made a grimacing face as the treatment nurse initiated the cleaning of the wound. The staffing coordinator indicated the cleaning must hurt by the face Resident #52 was making. The treatment nurse stated he was unsure if the moaning was pain or how Resident #52 was positioned. During the repositioning of Resident #52 the surveyor noticed two skin concerns. The treatment nurse indicated he was unaware of these two areas. Resident #52 had a 2.5 cm x 0.5 cm x 0.1 cm stage 2 pressure injury, and a 0.5 cm x 0.5 cm fluid filled blister to the right heel. The treatment nurse indicated Resident #52 should have had some heel protection boots on. During an interview after the wound care the treatment nurse indicated Resident #52’s grunting, moaning, and grimacing was demonstration of pain. The treatment nurse indicated he should have stopped the procedure and obtained pain medication. The treatment nurse indicated he did not stop the wound care, assess Resident #52 because he was in a hurry to finish. The treatment nurse indicated even though Resident #52’s wound looked bad it was actually better in his opinion. The treatment nurse indicated the antibiotic therapy and the Daiken’s wound solution was helping the odor.

During an interview on 11/07/22 at 1:51 p.m., CNA F indicated she was the CNA providing care to Resident #52. CNA F indicated she had not noticed Resident #53’s two new wounds on her right heel.

The Administrator and DON were notified 11/07/22 at 5:02 p.m. that an Immediate Jeopardy (IJ) was identified due to the above failures. The IJ template was provided on 11/07/22 at 5:05 p.m