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Based on record review, interview and policy review, the facility failed to identify a pressure ulcer on the back of a patient's head, failed to ensure a patient was receiving personal care with hair washing, and failed to ensure nursing care was provided to meet the patient's needs. This affected one (Patient #3) of ten patients reviewed.

See A396

Based on record review, interview and policy review, the facility failed to ensure a pressure ulcer was identified and failed to ensure a patient was receiving hair washing with personal care. This affected one (Patient #3) of ten medical records reviewed. The facility census was 195.

Findings include:

1. Review of the Patient #3's medical record revealed the patient was admitted to the facility on 08/15/22 with acute encephalopathy and COVID-19. The patient was discharged 09/12/22.

Review of the Patient #3's wound care note dated 09/09/22 revealed the patient had a full thickness unstageable wound to the posterior head with a recommendation of Mepilex (foam absorbent dressing) and offloading was made.

Review of the medical record revealed no documented evidence the patient had a pressure ulcer on the back of her head prior to 09/09/22.

Review of Staff I's complaint investigation, dated 09/23/22, revealed there was an unstageable pressure injury found in the operating room (OR) while Patient #3 was turned on her side for the debridement of a coccyx ulcer. Patient #3's hair was matted over the area and the surgeon clipped the area for better viewing. There was no previous documentation in regard to that particular wound. Review of the chart in detail revealed the patient had very poor mobility and was very rigid from Parkinson's. The patient was turned at appropriate intervals and all other pressure prevention measure were in place. The head wound was missed due to hair covering the area.

Review of Staff H's complaint investigation, dated 09/23/22, revealed the patient had not had much interaction during her stay but would shake his/her head a lot at times which matted his/her hair together and rubbed a wound to the head which was found in the OR.

Interview with Staff H on 10/31/22 at 4:00 PM revealed the patient had Parkinson's and dementia. The patient had a tic of a head movement which probably attributed to the area on the back of her head. The area was covered with matted hair and was not identified until the surgery to debride the coccyx wound.

Interview with Staff G on 11/01/22 at 12:30 PM confirmed the above findings during the Patient #3's chart review.

Review of the policy titled "Skin Care Management", effective 02/01/22, revealed all patients will be assessed for impaired skin integrity and the potential to develop impaired skin integrity using the Braden Scale.

2. Review of Patient #3's personal care sheet revealed the patient received a bath or peri care every day except for 08/16/22, 08/17/22, 08/18/22, 08/19/22, 08/28/22, and 09/03/22.

Review of the documentation revealed the patient's hair was washed on 09/04/22. There was no documented evidence the patient had her hair washed any other day while in the hospital.

Interview with Staff G on 11/01/22 at 12:30 AM confirmed the above findings.

Review of the policy titled "Skin Care Management", effective 02/01/22, revealed a daily bath was offered to all patients using Soothe & Cool Shampoo and Body Wash. Avoid using bar soap and avoid hot water.