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Based on record review, interview and policy review, the facility failed to ensure a resident received care and services to prevent the development of a pressure ulcer. The patient census was 346.

See A395

Based on record review, interview and policy review, the facility failed to ensure a resident received care and services to prevent the development of a pressure ulcer. The patient census was 346.

Findings include

Review of the medical record revealed Patient #3 was admitted to cardiovascular step-down unit (CVSU) on 04/22/24 at 2:40 AM. Patient #3's Braden score was 18, which was mild risk for skin breakdown. Interventions to prevent skin breakdown included a Mepilex dressing to the coccyx, keeping skin dry, linen clean and dry, and repositioning Patient #3. Patient #3 required assistance with turning and repositioning. Patient #3 was incontinent of bowel and bladder on admission and had a Purewick catheter placed. There were no pressure ulcers present on admission.

Review of the medical record revealed on 05/03/24, a Friday, at 6:00 PM, a stage II pressure ulcer was discovered to Patient #3's sacral area. The area was cleaned with normal saline, a moisture barrier cream and then Mepilex was applied. An image was taken of the sacral area. There was also a consult order placed to the wound nurse on 05/03/24. There is no wound care nurse on the weekends. The wound care nurse assessed the wound on Monday 05/06/24. The area measured 1 centimeter (cm) by 2 cm by 2 cm. Another image was taken. The surrounding skin texture was friable and the color and temperature was consistent with the rest of her skin. The orders by the wound care nurse were for a cream moisture barrier two times a day and as needed and Mepilex. There were also orders to re-consult the wound care team if the wound were to worsen.

Review of the flow sheet revealed the Mepilex to the coccyx was not documented as being place on 04/29/24 and 04/30/24.

Review of Patient #3's flow sheet for turning and repositioning revealed on 04/22/24 no documentation Patient #3 was turned and repositioned from 2:50 PM to 6:18 PM and then again from 9:20 PM to midnight; on 04/27/24 from 5:00 PM to 8:35 PM up in chair sitting semi-fowlers; on 04/29/24 from 3:30 PM to 8:00 PM up in chair; and on 05/03/24 from 1:01 PM to 4:05 PM, up in chair.

Review of the medical record revealed images of Patient #3's coccyx on 05/03/24, 05/05/24, 05/06/24, and 05/09/24 and the area looked the same. Patient #3 was discharged on 05/13/24 to a skilled nursing facility (SNF).

Review of a complaint filed by Patient #3's representative on 05/03/24 revealed the representative reported that physical therapy (PT) wanted Patient #3 up in the chair while she is eating. The representative visited on 05/03/24 at 3:00 PM and Patient #3 said she had been up in the chair since that morning. When staff got Patient #3 up from the chair, her brief was soiled with feces. The Purewick external catheter was not working properly which caused the brief to be full of urine.

Review of a nurse practitioner palliative care progress note dated 05/07/24 documented Patient #3's representative R made a strong goal for her to be out of bed at mealtime and is very important to maintain every two hour turns due to the pressure ulcer on the buttock.

During an interview on 10/09/24 at 3:28 PM, the Assistant Manager of CVSU stated Patient #3 had three episodes of bowel incontinence on 05/03/24 at 1:30 AM, 5:00 AM and 10:00 AM. Peri care was documented at 1:30 AM and 10:00 AM, but there was no documentation of peri care at 5:00 AM.

During an interview on 10/10/24 at 4:30 PM, Staff D confirmed the above information.

Review of the policy titled "Pressure Injury Prediction, Prevention, and Treatment", revised November 2021, stated it is the goal of the hospital to prevent pressure injury development in all patients while receiving care in our facilities. Patients who develop pressure injuries while receiving care in any of our facilities will receive assessment and treatment for their skin breakdown with a goal toward healing and prevention of wound deterioration.

A component of the assessment may include, but is not limited to, photography. Photographs will be taken to provide documentation of each patient's pressure injury and serve as a resource for quality assessment as well as re-evaluation.

Prophylactic pressure redistribution dressing is to be used for patients at high risk for skin breakdown with a Braden score of less than 18 or equal to and should have approved pressure re-distribution dressing applied over bony prominences at high risk for pressure including the coccyx area.

For urinary incontinence consider the use of external catheter options when applicable.

Pressure injury for Stage 1 or Stage 2 is including pressure injuries can be managed by nursing staff. The nurse may consult the Wound Nurse if the wound is not responding to standard care or the primary nurse identifies that the patient has factors inhibiting would healing. Initiate all preventative interventions to prevent further deterioration of the wound.

Review of the guidelines for Mepilex border revealed it can be used for up to seven days.