State Findings:
During an annual survey, the following deficient practice was found to be Immediate Jeopardy:
1) R #110 developed three facility acquired (developed in the facility) pressure ulcers. One on the coccyx (the bottom portion of the spine), one on the left heel, and one on the right heel. The left heel healed. The right heel was unstageable (not able to be staged). The pressure wound on the coccyx progressed to a Stage IV (reaching into muscle and bone).
2) Record review of R #110’s care plan revealed weekly skin assessments to include measurements and description of wound status. Record review of R #110’s wound tracking assessments revealed only one assessment in (MONTH) ([DATE]) and no assessments (MONTH) 2019 were found.
3) The staging from the Nurse Practitioner, the Physician’s assistant, and the Physician reflect an initial stage of R #110’s coccyx pressure wound as Stage II that worsened. On [DATE], the Nurse Practitioner staged R #110’s coccyx wound as Stage III (extends into the tissue beneath the skin). On [DATE], the Nurse Practitioner staged R #110’s coccyx wound as a Stage IV. On [DATE], the Physician’s assistant staged the coccyx wound as a Stage IV. On [DATE] and [DATE], the Physician staged the coccyx wound as a Stage IV. The wound assessments completed by the facility staff stage the coccyx wound as a Stage II (skin breaks open expands to the deeper layer of the skin) until [DATE].
4) Only one nurse in the facility had completed the wound treatment training. Also, only one nurse (a separate nurse) in the facility had completed pressure wound staging.
5) The nurse providing wound care for R #110 did not have any nursing competency for any nusing care.
6) Observations of wound care revealed improper infection control practices: a) hand hygiene, b) aseptic (clean) technique, c) and the return of contaminated wound care supplies to the common stock to be used for others, and
7) In (MONTH) 2019, the doctor ordered R #110 to have an air mattress for pressure relief. The air mattress was not implemented for R #110.
This resulted in an Immediate Jeopardy that was called on [DATE] at 3:40 pm. A Plan of Removal was submitted on [DATE] at 9:20 am, and 11:20 pm were rejected. On [DATE] at 11:40 am the final Plan of Removal was approved.
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