TULSA, OK- MAPLEWOOD CARE CENTER

This facility has been on Nursing Homes Abuse Advocates’ Special Focus Facilities list for 3 months. 

Based on record review, observation, and interview, the facility failed to ensure pressure ulcers received necessary treatment and services per physician orders for three residents (#77, 6, and #70) of three residents reviewed for pressure ulcers.

The census and condition form documented 16 residents with pressure ulcers.
Findings: 1. Resident (Res) #77 was admitted on [DATE] with diagnoses which included pressure ulcer of sacral region.

A re-admission MDS assessment, dated 12/13/21, documented the resident was cognitively impaired and was total dependent of two staff for all ADLs. The assessment documented the resident had two Stage IV pressure ulcers upon re-entry to the facility.

A care plan, date unknown, documented in parts .admitted with 3 Pressure ulcers; coccyx, right upper buttock, left outside ankle. Potential for deterioration of wounds r/t overall poor health status and multiple co-morbidities .

A physician order, dated 02/11/22, documented in parts .Wound Treatment Order: Location: Left ischium, Clean with Normal Saline/Wound Cleanser, Apply: Santyl, Cover with Primary Dressing: Soft Silicone bordered dressing and Secure Once A Day . and .Wound Treatment Order: Location: sacrum, Clean with Normal Saline/Wound Cleanser, Apply: santyl, Saline moistened gauze, Cover with Primary Dressing:

Secure with foam border dressing (silicone-Sacrum) Once A Day .

02/14/22 2:19 p.m., the resident was observed lying on her right side with the HOB elevated. The resident was observed lying on an air flow mattress.

02/15/22 at 7:40 a.m., the resident was observed lying on their back with the HOB elevated. The resident was observed lying on an air flow mattress.

On 02/17/22 at 9:27 a.m., LPN #1 was observed performing pressure ulcer care. LPN #1 removed the old dressing, dated 02/14/22. The resident had two pressure ulcer located on the left ischium and on the sacrum.

LPN #1 reported the left ischium pressure ulcer was unstageable due to slough and the sacrum pressure ulcer was stage IV. LPN #1 reported if the wound care was ordered daily, it should have been done daily.

LPN#1 reported it was the first time she had observed the residents wounds. LPN #1 stated the physician observed the pressure ulcers today and was in the process of changing her pressure ulcer orders.

On 02/22/22, the DON reported the pressure ulcer care should have been performed as ordered.

2. Res #6 had diagnoses which included end stage renal disease, a stage 4 pressure ulcer, and diabetes mellitus.

A physician order, dated 02/01/22, documented daily to clean the left buttock with normal saline and wound cleanser, pat dry, and apply Santyl (a medication to prevent worsening of pressure ulcers), and cover with primary dressing and cleanse the sacrum with normal saline and wound cleanser, pat dry, and apply Medihoney(a debridement medication for pressure ulcers), and cover with a border foam dressing and secure.

An admission MDS assessment, dated 02/08/22, documented the resident was cognitively intact, totally dependent on staff for activities of daily living, required dialysis, and had a stage 4 pressure ulcer.

An nursing admission assessment, dated 02/09/22, documented the resident’s skin condition had a stage 4 pressure ulcer sacrum.

On 02/15/22 at 3:31 p.m., Res #6 reported wound care was performed every three to four days.

On 02/16/22 at 3:15 p.m., during wound care observation, LPN #1 removed the primary dressing from the buttocks of the resident. The border foam dressing was removed from the sacral area, LPN#1 displayed the date and the border foam dressing was dated 02/04/22. LPN #1 stated the residents wound care must not have been performed since 02/04/22 and should have been.

On 02/17/22 at 10:15 a.m., the DON reviewed the MARS and reported pressure ulcer treatments had been missed on 02/07, 02/11, and 02/15/22 and should have been done.

3. Resident (Res) #70 had diagnoses which included pressure ulcer of sacral region, stage 4.
A admissions MDS assessment, dated 12/05/21, documented the resident was intact with cognition, required extensive assistance with activities of daily living, and had 3 stage four pressure ulcers upon admission.

A care plan, last revised 02/04/22, documented in parts .treatment for wounds as ordered including wound vac .

On 02/14/22 at 1:10 a.m., Res #70 was observed lying in bed.

A physicians order, dated 02/09/22, documented to start Pro-stat (a liquid protein that promotes tissue healing) 45 cc by mouth twice a day.

A physicians order, dated 02/15/22, documented to hold Pro-stat until available.
Review of the resident clinical record, the resident had not received Pro-stat for 7 days.

On 02/22/22 at 2:36 p.m., the dietitian stated there was not any Pro-stat in the facility after the order. The resident had not been getting it.

On 02/22/22 at 3:07 p.m. the DON stated the Pro-stat had been ordered and the resident did not receive Pro-stat for 7 days after the order.