State Findings:
A review of Resident 34’s Skin Check Record dated November 26, 2020, at 4:07 p.m. revealed skin injury type: pressure, location: bilateral buttocks. The record failed to identify the measurement, and characteristics of the resident’s wounds.
Resident 34’s Wound Evaluation Record dated November 27, 2020, at 3:23 p.m. revealed right buttock Stage 3 and left buttock Stage 3. Also documented was a Sacrum DTI (Deep Tissue Injury).
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 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)
Facility failed to provide a consistent wound treatment, ensure that wound assessments were done timely, comprehensively, and accurately which resulted in actual harm when Resident 34’s sacral wound had advanced from a DTI to an unstageable pressure ulcer.
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