State Findings:
Based on review of the facility’s policy and procedure, clinical record review, and staff interview, it was determined that the facility failed to provide wound treatment consistently, assess the wound timely, accurately, and comprehensively for one of seven residents reviewed, resulting in actual harm when the resident’s sacral wound deteriorated (Resident 34).
A review of Resident 34’s Admission Minimum Data Set assessment (MDS-an assessment tool used to facilitate the management of care) dated December 2, 2020, revealed that the resident’s cognition was moderately impaired. The same MDS revealed that the resident required extensive assistance with two people for bed mobility. The MDS also revealed that the resident was always incontinent of bladder and bowel.
An interview with RN Employee E6 on May 6, 2021, at 2:50 p.m. confirmed that Resident 34’s wounds were not assessed on the first and second weeks of December 2020. RN Employee E6 stated that the nurses and/or wound nurse were responsible for the weekly assessment of the wounds. RN Employee E6 was unable to provide an answer as to why the wounds for Resident 34 were not assessed on the first and second weeks of December 2020.
A review of the Wound Evaluation Record dated December 23, 2020, at 9:14 a.m. revealed that the sacral wound had deteriorated and is now a Stage 4 pressure ulcer (ulcer involving loss of skin layers, exposing muscle and bone), with measurements of 4.88 cm x 3.41 cm x 1.5 cm, 70% slough (black), 30% granulation, with light purulent exudate (a type of fluid that is released from the wound often described as being milky and can indicate sign of infection). NP was made aware, a new treatment order was made on December 23, 2020, to cleanse sacrum with wound cleanser and pack two fluffed Mesalt (supports the cleansing of moderately to heavily discharging infected wounds) dressing and cover with foam every day shift. A review of the left buttock Stage 3 revealed a measurement of 0.11 cm x 0.3 cm x 0.35 cm.
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If you have or had a loved one living in this nursing home or any other nursing home where you suspect any form of abuse or neglect, contact us immediately.
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Personal Note from NHA-Advocates
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