State Findings:
The facility failed to identify a pressure ulcer to R #24s heal until it was unstageable (full thickness skin or tissue loss with unknown depth) – 4.0 cm X 7.0 cm – on 08/25/20. On 10/27/20 the resident was sent to the emergency room with a fever. He was diagnosed with [REDACTED]. On 11/09/20 a left [MEDICAL CONDITION] was performed.
This deficient practice resulted in an Immediate Jeopardy (IJ) at a scope and severity of J being identified on 12/09/20. The facility was notified on 12/09/20 at 12:30 pm.
On 12/09/20 at 8:50 am during a phone interview the Acting Director of Nursing (A-DON), he was unable to explain how R #24’s left heel pressure ulcer developed without being noticed until it was unstageable and the how the wound increased from 3.0 cm X 3.0 cm on 10/20/20 to a unstageable pressure ulcer measuring 6.0 cm X 3.0 cm on 10/27/20.
Record review of Weekly Skin Integrity Review for R #24 revealed, skin reviews were done on 05/23/20, 05/28/20, 06/04/20, 06/11/20 and 06/18/20. No other Weekly Skin Integrity Reviews were found.
Record review of the Medical Record of R #24 did not identify that pressure wound prevention methods were implemented, including no evidence that R #24 was repositioned/turned to relieve pressure.
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