MARYSVILLE, WA- MOUNTAIN VIEW REHABILITATION AND CARE CENTER

Based on observation, interviews, and record reviews, the facility failed to ensure that two of four residents (49 and 51) reviewed for pressure ulcers received care and services to prevent, monitor, and treat pressure injuries. This failure resulted in both residents’ deep tissue injuries to progress into advanced stages of pressure ulcers resulting in gangrene and amputation of Resident 49’s right above the knee lower extremity, constituting an immediate jeopardy.

On 04/21/2022 at 6:20 PM, Staff E, the Oversight Administrator (OA), Staff F, Chief Officer of Operations (COO), and Staff I Registered Nurse (RN)/Clinical Resources, were notified that the facility’s failure to ensure Resident 49 was provided care and services to prevent them from sustaining a PU constituted immediate jeopardy at F686-J: Treatment/Services to Prevent/Heal Pressure Ulcers.

Review of Resident 49’s quarterly Minimum Data Set (MDS), located in the EMR under the tab MDS, with an Assessment Reference Date (ARD) of 10/25/2021, (prior to resident’s pressure ulcer), revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15, which indicated Resident 49 was cognitively intact. This MDS assessment revealed Resident 49 did not exhibit any behaviors, including the rejection of care and was assessed as being at risk for developing pressure ulcers/injuries. There were no pressure ulcers/injuries documented at the time of this MDS assessment. This MDS assessed Resident 49 as requiring extensive assistance of one person for bed mobility and transfers.

Review of Resident 49’s Physician Orders, Progress Notes, Treatment Administration Record (TAR), wound care notes located in Resident 49’s EMR for the Months of January, February, and March 2022 revealed the following orders were not completed on the noted dates:
-01/27/22 Right heel wound: Cleanse with NS, pat dry, apply iodasorb (a medication used for wound treatment) to wound bed, secure with super absorbent dressing every dayshift for DTPI. This was not completed on dates: 01/29/2022, 01/30/2022, 02/10/2022, 02/19/2022, 02/22/2022, and 02/27/2022.
– Offload bilateral heels at all times(sic) while in bed every shift. This was not completed on dates: 01/17/2022(nights), 01/23/2022 (days) 01/29/2022(days) and 01/30/2022 (days), 02/02/2022 (nights), and 02/27/2022 (nights);
– Offloading boots to bilateral heels at all times(sic) while in bed. Document compliance every shift for Right heel wound. This was not completed on dates: 01/17/2022 (nights), 01/23/2022 (days), 01/29/2022(days), 01/30/2022 (days), 02/02/2022 (nights), and 02/27/2022 (nights); and
– Left heel treatment: Cleanse with NS, pat dry, paint with [MEDICATION(S)]. Ensure black off-loading boot is in place! Every-day shift for boggy and unblanchable (assessment sign to indicate pressure injury) heel. This was not completed on 02/19/2022.

Review of Resident 49’s Progress Notes dated 03/03/2022, located in Resident 49’s EMR under Progress notes, revealed resident has DTI (deep tissue injury) right heel and left heel wound infection, right heel wound condition got worse as unstageable pressure ulcer with necrosis and eschar, (practitioner notified), ordered to transfer the resident to hospital as resident need aggressive treatment .

Review of practitioner’s Progress Note dated 03/24/2022, located in Resident 49’s EMR, under Misc. tab, revealed .initially presented to [medical center] on 03/03/2022 for worsening of chronic bilateral heel pressure ulcers. In the emergency room (ER), patient received antibiotics and intravenous fluids, and admitted for further care. During the hospital course the patient was treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . During hospital course, patient underwent right above knee amputation (AKA) .family has elected to place resident on Hospice care.