Based on interview and record review it was determined the facility failed to follow physician's orders as a result a resident developed two pressure ulcers, unstageable due to eschar for 1 of 3 sampled residents (#2) reviewed for pressure ulcers. This placed residents at risk for pressure ulcers, delayed healing and inappropriate treatment. Findings include:
The Minimum Data Set 3.0 User's Manual revealed eschar is dead or devitalized tissue that is hard or soft in texture; usually black, brown, or tan in color, and may appear scab-like. Necrotic tissue and eschar are usually firmly adherent to the base of the wound and often the sides/edges of the wound.
The 2016 revised National Pressure Injury Advisory Panel, NPIAP Pressure Injury Stages revealed "Unstageable Pressure Ulcer: Obscured full-thickness skin and tissue loss Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar. Stable eschar (i.e. dry, adherent, intact without erythema or fluctuance) should only be removed after careful clinical consideration and consultation with the resident's physician, or nurse practitioner, physician assistant, or clinical nurse specialist if allowable under state licensure laws. If the slough or eschar is removed, a Stage 3 or Stage 4 pressure ulcer will be revealed. If the anatomical depth of the tissue damage involved can be determined, then the reclassified stage should be assigned. The pressure ulcer does not have to be completely debrided or free of all slough or eschar for reclassification of stage to occur".
Resident 2 was admitted to the facility in 1/2020 with a right femur fracture, osteoarthritis and osteoporosis.
Resident 2's 2/2020 Admission MDS revealed the resident had a BIMS score of 5 (severely impaired cognition), required staff assistance for ADL cares including mobility, transfers and locomotion. Resident 2 had no identified pressure ulcers.
Resident 2's undated Admission Care Plan/SNF Care Plan revealed the resident was bed bound and required two-person mechanical lift for transfers. The resident had a femur fracture requiring the use of an immobilizer (splint/brace for stabilization) and had as needed pain medication.
The 1/27/20 Physician Orders revealed Resident 2 was non-weight bearing on her/his right lower extremity. Maintain the knee immobilizer when out of bed and perform skin checks under the immobilizer daily. A Hoyer lift was recommended until Resident 2's strength recovered.
The facility could not find Resident 2's 1/2020 clinical records to support Resident 2 received care as ordered by the physician.
Progress Notes reviewed revealed the following:
-On 1/31/20 the resident's skin under the immobilizer was clean, dry and intact [the only documented occurrence the resident's skin under her/his immobilizer was evaluated];
-On 2/11/20 at 4:00 AM the resident complained of severe leg pain and pain medication was provided;
-On 2/11/20 at 11:00 PM the resident had a sore area to her/his right calf area, the area was slightly red and warm to touch. Resident 2 had two dark areas to the posterior calf. The proximal dark area measured 3 cm by 1 cm, the distal area measured 1 cm by 1 cm. The physician was notified and the resident was sent to the emergency department (ED) for evaluation.
The hospital records revealed the following:
-On 2/11/20 the resident was evaluated in the ED;
-On 2/12/20 Resident 2 was admitted in-patient to the hospital and had complaints of feeling fatigued and right leg pain. The resident was alert and oriented to self and event, had pain with movement and was conversational. The resident had two small pressure ulcers with eschar and the base of the wounds were not visible. The resident's right leg had pitting edema and erythema (skin redness caused by inflammation) with warmth. The resident was diagnosed with cellulitis (skin infection that causes pain, redness and swelling) and pressure ulcers caused by a device. The resident was started on IV antibiotics.
-On 2/13/20 and 2/14/20 the resident continued to receive IV antibiotics for cellulitis.
-On 2/14/20 the resident was discharged from the hospital back to the facility.
In an interview on 3/9/21 at 12:07 PM and 3/11/21 at 3:20 PM Staff 2 (DNS) stated Resident 2 complained of pain, the nurse evaluated the resident's leg and found two pressure ulcers. The physician was notified, Resident 2 was sent to the ED for evaluation, and was admitted to the hospital for further treatment. Staff 2 stated she completed an investigation and the nurses were not checking Resident 2's skin under the immobilizer which resulted in two pressure ulcers and cellulitis. Staff 2 stated the facility recognized the error and implemented a plan of correction.
In an interview on 3/11/21 at 10:07 AM Staff 3 (RN) stated she could not recall much detail about Resident 2 but knew she/he had a brace on her/his leg. Staff 3 stated in approximately one week the resident developed two sores but should not have.
In an interview on 3/11/21 at 2:20 PM Staff (RCM) stated Resident 2 admitted with a brace on her/his leg because of a fracture and developed pressure ulcers under the brace.
The facility completed the following by 2/14/20 to ensure no further facility acquired pressure ulcers occurred:
-Resident 2 was immediately sent to the emergency department for evaluation;
-Facility wide audit of orders and skin assessments for residents;
-Education was provided to nursing staff and administration regarding policies and procedures related to order entry, treatment procedures and care plan development for residents presenting with braces and/or casts;
-Audits of care plans, care directives and TARs were conducted weekly for four weeks and monthly for two months.
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OAR 411-086-0140 Nursing Services: Problem Resolution & Preventive Care
Refer to F686
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