MACON, GA – PRUITTHEALTH – PEAKE

Based on observation, record review, review of the facility’s Lippincott Procedure and staff interviews, the facility failed to ensure that wound assessments were completed weekly for three of 10 sampled residents (R) (#1, #2, and #4) with pressure ulcers; and failed to conduct consistent weekly skin assessments and failed to notify the Physician for appropriate wound treatment orders for R#1.

On 3/4/21 a determination was made that a situation in which the facility’s noncompliance with one or more requirements of participation caused or had the likelihood to cause serious injury, harm, impairment, or death to residents.

The facility’s Administrator and Director of Health Services (DHS) were informed of the Immediate Jeopardy (IJ) on 3/4/21 at 11:18 a.m. The noncompliance related to the IJ was identified to have existed on 12/3/2020.

R#1 was admitted to the facility on [DATE] with no alterations in skin and was assessed as at risk for pressure ulcers. On 12/3/2020, a Stage 2 pressure ulcer was observed on the right buttocks measuring 2 centimeters (cm) x 3 cm. A wound treatment was started. However, the Physician and family were not notified. On 1/17/21, a Stage 3 pressure ulcer to the sacrum was identified measuring 3 cm x 4 cm. On 1/23/21, the sacrum and right buttocks pressure ulcers combined and measured 10.5 cm x 7.5 cm. A wound observation assessment was completed indicating that the wound was declining. The wound treatment was changed. However, the Physician and family were not notified. The Physician became aware of the pressure ulcer on 2/2/21 when making rounds. He identified an unstageable pressure ulcer to the sacrum with a foul odor, drainage, and necrotic tissue. R#1 was hospitalized due to wound infection and [CONDITION(S)]. R#1 was transferred to another nursing home and is receiving palliative care. There was no evidence that skin assessments were consistently done weekly and only three wound assessments were completed from November 2020 through January 2021.

Interview with the Physician on 3/3/2021 at 3:27 p.m. revealed that he seen the resident that day for [CONDITION(S)] and a change in mental status. The resident also had COVID. He entered the room and smelled a foul odor and then looked at the wound. The wound was draining and there was necrotic tissue in the wound. He knew, upon observation, that the wound was unstageable. He knew by her other symptoms that she had some sort of infection. He did not feel that the wound got infected overnight, and was most likely infected for several days, likely when they found it 1/25/2021 (sic, 1/23/21). He expected them to call him any time there is a change in condition, especially when they have a wound, so that they can evaluate if the treatment was appropriate. The Physician stated he expects the nurses to do body audits and weekly wound assessments so they can review them and determine if the wound is healing or if the order needs to be changed. He has not been able to do that (review documentation) and has had to rely on communication with the nurses for wound status. He stated R#1 fell through the cracks and this could have been prevented.