LITTLE ROCK, AR – MIDTOWN POST ACUTE AND REHABILITATION – A WATERS C

Based on observation, record review and interview, the facility failed to ensure a pressure ulcer to the left heel was identified so treatment could be promptly initiated to prevent further deterioration for 1 (Resident #2) and weekly skin assessments were completed and documented for 2 (Residents #2, and #5) of 4 (Residents #1, #2, #3, and #5) sampled residents who had pressure ulcers. This failed practice resulted in actual harm to Resident #2 who was not receiving weekly body audits and had an unstageable pressure ulcer to the left heel that had not been identified by staff and was not being treated.

The facility failed to ensure the wound care dressings were applied as needed and the correct dressing was applied to 1 (Resident #5) of 4 (Residents #1, #2, #3, and #5) sampled residents who had orders for wound care and failed to ensure

On 9/24/21 at 12:35 P.M., Licensed Practical Nurse (LPN) #1 was asked, How long has [Resident #2] been wearing the boot on his left heel? She stated, He’s been wearing it for a couple of months. She was asked, How often do you remove it? She stated, He’ll ask the CNA’s [Certified Nursing Assistants] to take it off. She was asked, Why is he wearing the boot? She stated, He has a wound on his left heel. I don’t think it’s open. She was asked, How long has he had the area to his left heel? She stated, Maybe it was a stage 1 non-blanchable probably over a month ago. She was asked, Who is responsible for doing the skin assessments? She stated, Treatment nurse. She was asked, Who ordered the boot? She stated, I think the PA [Physician Assistant]. The nurse got the PA to approve it probably.

 On 9/24/21 at 12:38 P.M., CNA #2 was asked, Do you work with [Resident #2]? She stated, I worked with him a couple of weeks ago. She was asked, Were you informed that [Resident #2] had a pressure ulcer to his left heel? She stated, No, the splint was on there when I got here.

On 9/27/21 at 10:08 A.M., the Treatment Nurse removed the boot from Resident #2’s left heel. There was a black area observed on his heel. The resident stated Ouch when the treatment nurse touched his heel.

On 9/27/21 at 11:43 A.M., the Wound Care Nurse was asked, How long has [Resident #2] had the wounds on his left foot? He stated, I just found out when you asked me to assess him.

On 9/27/21 at 11:55 A.M., CNA #1 was asked, How long had [Resident #2] had the wounds on his left foot? She stated, I don’t know.

On 9/27/21 at 1:27 P.M., CNA #3 was asked, How long had [Resident #2] had the wounds on his left foot? He stated, Far as I know he has had it a long time. He has a red area on his chest. I notified the nurse.

On 9/27/21 at 2:55 P.M., the Director of Nursing (DON) was asked, Who’s responsible wound assessments? She stated, Treatment nurses and nurses on the floor. She was asked, How long has [Resident #2] had the wounds on his left foot? She stated, Not positive.