RICHMOND, KY- MADISON HEALTH AND REHABILIATATION CENTER

Based on observation, interview, record review and review of the Resident Assessment Instrument (RAI), Version 3.0, dated 10/2019, it was determined the facility failed to implement the Comprehensive Plan of Care related to pressure ulcers for four (4) of thirty-three (33) sampled residents (Residents #19, #39, #47, #63).

Review of the Comprehensive Care Plan for Resident #47 revealed the Comprehensive Care Plan (CCP) interventions included: assess the skin and report skin breakdown; treatments as ordered; treatment to the Deep Tissue Injury (DTI) to right outer foot and monitor until resolved; treatment to the left heel as ordered; and treatment to the left outer foot as ordered. However, there was no documented evidence the facility was monitoring the resident’s wounds, as there was no Wound Assessment completed from 01/13/2020 until 02/16/2022, after Surveyor intervention. Further, there was no documented evidence treatments were performed as ordered. The resident’s pressure ulcers deteriorated and he/she developed Osteomyelitis (a bone Infection).

Review of the Comprehensive Care Plan for Resident #19 revealed the Comprehensive Care Plan (CCP) interventions included: assess skin and report redness, rashes, bruises, abrasions or skin breakdown; provide wound care as ordered by the physician; and provide medications and treatments as per orders. However, there was no documented evidence the facility was monitoring the resident’s wounds nor was there documented evidence Physician’s orders were implemented related to wound care. There was no initial Wound Assessment until until 12/07/2021, twenty-eight (28) days after admission. Additionally, there was no documented evidence of a Wound Assessment from 12/07/2021, until the surveyor requested to observe a skin assessment on 02/16/2022, seventy-one (71) days later, when the resident’s wounds were noted to be larger and unidentified wounds were noted.

Review of the Comprehensive Care Plan for Resident #39 revealed the Comprehensive Care Plan (CCP) interventions included: Staff were to assess skin and report redness, rashes, bruises, abrasion or skin breakdown; pressure reduction mattress; provide incontinent care as needed; provide wound care as ordered by the MD. However, there was no documented evidence the facility was monitoring the resident’s wounds nor was there documented evidence Physician’s orders were implemented related to wound care. No documented evidence of a wound assessment from 01/11/2022 until the surveyor requested to observe skin assessment on to 02/16/2022, thirty-six (36) days later, the wound has worsened with a tunneling noted at 6.5 cm.

Review of the Comprehensive Care Plan for Resident #63 revealed the Comprehensive Care Plan (CCP) interventions included: Staff were to assess skin and report redness, rashes, bruises, abrasion or skin breakdown; pressure reduction mattress; provide incontinent care as needed; provide wound care as ordered by the MD; treatment to stump per order. Review of Care Plan dated 02/04/2022 revealed new treatments for Resident #63’s stage II coccyx and Left AKA was not updated on the care plan until 02/07/2022. No documented evidence of wound assessment for residents left AKA until the surveyor requested to observe skin assessment on to 02/16/2022.

Interview, on 02/16/2022 at 1:40 PM, with the Education Director, revealed the nurses were responsible for the skin assessments and wound treatments at this time. She was unaware skin assessments and wound treatments were not being completed as ordered and revealed the CCP was to be implemented related to skin breakdown.

Interview with Registered Nurse (RN) #1, on 02/19/2022 at 2:42 PM, revealed she had not been completing Wound Assessments. She further stated the nurses had not been trained to do Wound Assessments and she was not sure which staff member was responsible for completing them.