PADUCAH, KY – STONECREEK HEALTH AND REHABILITATION

Based on observation, interview, record review, and review of facility’s policy, it was determined the facility failed to provide care and services consistent with professional standards of practice to promote the prevention of pressure ulcer/injury development and the healing of existing pressure ulcers/injuries for two (2) of four (4) sampled residents (Residents #1 and #5).

On 12/02/2020, the facility readmitted Resident #5 from the hospital with a Stage II pressure ulcer to his/her right buttock. The facility failed to document the description of wound characteristics (skin type and exudate), obtain a physician order to treat the pressure ulcer, complete a weekly skin assessment until 12/16/2020; and complete a weekly wound assessment until 12/19/2020. On 12/19/2020, (seventeen {17} days later), the pressure ulcer on the right buttock had worsened (larger) and two (2) additional Stage II pressure ulcers to his/her left buttock were identified.

In addition, the facility assessed Resident #1 to have pressure wounds and require the extensive assistance of two (2) or more staff with bed mobility. Observations revealed the facility failed to turn and reposition Resident #1, from side to side, for more than 2 hours (from 12:00 PM-2:40 PM) in order to prevent further skin breakdown and promote healing.

Interview with Resident #5’s Sister, on 02/10/2021 at 6:30 PM, revealed Resident #5 was readmitted to facility on 12/02/2020 due to COVID-19. She stated she was aware the resident had a small pressure ulcer on the right buttock upon return to the facility. Continued interview revealed the facility failed to provide care to the pressure ulcer on the resident’s right buttock and it worsened. She stated in addition to my (resident) wound getting worse, they let (him/her) acquire two (2) major open wounds on (his/her} buttocks; which was the reason for the transfer to the other facility.