cms_SD: 43
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| rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 43 | MONUMENT HEALTH CUSTER CARE CENTER | 435032 | 1065 MONTGOMERY ST | CUSTER | SD | 57730 | 2018-03-28 | 686 | H | 0 | 1 | CZRE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, manufacturer's review, and policy review, the provider failed to ensure four of five sampled residents (21, 41, 47, and 53) who required staff assistance with care had not developed facility acquired pressure injuries. Findings include: 1. Review of resident 41's medical record revealed: *She had been admitted on [DATE]. *She had short and long term memory problems. *Her decision making ability was severely impaired. *Her [DIAGNOSES REDACTED]. *She was dependent on the staff to: -Anticipate her care needs. -Initiate and implement interventions to ensure her health and safety. *She developed facility acquired pressure injuries to both her heels on 2/19/18. -She also had skin concerns to both her great toes. Observation on 03/13/18 at 08:17 a.m. of resident 41 revealed: *She was laying in bed on her right side with her face covered with blankets. *She had one foam heel boot sitting on top of the covers. -It was not on her foot. Interview and record review on 03/13/18 at 10:09 a.m. with licensed practical nurse (LPN) D regarding resident 41 revealed he:*Was her charge nurse that day. *Was a traveling nurse and had been working there since 2/1/18. *Stated she had pressure injuries and treatments of: -Daily left heel and right heel pressure injury monitoring by the nurse. -A blister area to her right great toe. -[MEDICATION NAME] dressing to her left heel suspected deep tissue injury to be changed every three days as needed. -[MEDICATION NAME] dressing to her right heel suspected deep tissue injury to be changed every three days and as needed. *Stated he was already done with her treatments for the day. *Stated her [MEDICATION NAME] dressing changes were due to be changed on 3/14/18. -The surveyor requested to observe that dressing changed and he agreed stating he would be working again. Observation and interview on 03/13/18 at 11:06 a.m. with certified nursing assistant (CNA) supervisor I during resident 41's personal care revealed:*The resident was out at activities in her wheelchair. *The CNA wheeled her into her room and assisted her to the bathroom. *The resident was wearing small slippers and compression stockings to both legs. *The surveyor questioned if the resident had any skin concerns and the CNA stated:-When the resident had come back from the hospital she was in bed and a lot more sleepy than she had been before. -She thought the resident had some pressure areas on her buttocks and a spot on the back of her head. -The resident also had a history of [REDACTED]. -She did not mention any pressure areas to her heels. *The CNA offered to remove the resident's compression stockings and slippers to view the resident's legs and feet. *Her skin had: -Some scratch marks on her shins. -Dark brown/black scab-like areas to the backs of both her heels. -A darkened spot on the tip of her left great toe. -A callus-like area on the tip of her right great toe. *The surveyor questioned if the nurses had done treatments to those heel and toe areas. -CNA stated she was not sure but there was nothing on them when she had gotten her up that morning for breakfast or the day before when she had given her a bath. *The CNA questioned if the resident should be wearing her compression stockings when she had those areas on her feet. -The surveyor questioned her back and asked how she would find out that information. -The CNA stated she would refer to her CNA cheat sheet. *Review of that undated CNA cheat sheet revealed: -No mention of skin concerns for her. -She should have been wearing a compression stocking to her left leg only. -There was no mention of heel boots or when to wear them. *The CNA stated she thought the resident only needed to wear the heel boots when she was in bed. During the above interview and observation at 03/13/18 11:13 a.m. LPN D arrived to the resident's room: *The surveyor: -Requested he come in to look at the resident's feet and legs. -Asked him about the [MEDICATION NAME] dressings he said had been in place that morning. *He stated he had done her treatments around 5:00 a.m. and he thought the dressings were there. -He stated she should have the foam dressings on her heels and the foam boots on at all times. *He then left the room saying he would be right back. Continued observation and interview on 03/13/18 at 11:17 a.m. in resident 41's room revealed: *Registered nurse (RN) [NAME] and LPN D arrived back to the room. *RN [NAME] stated she oversaw the pressure injuries in the building and did the weekly measurements on them. -She stated the residents heel pressure injuries started as purple spongy areas about three weeks prior. -She thought they were looking better. *When the surveyor questioned what was in place for pressure injury prevention RN [NAME] stated they: -Put an air mattress on her bed. -Started the foam boots at all times. -Initiated the [MEDICATION NAME] dressing changes. -Notified the dietary department. *She confirmed all those interventions had been implemented after the pressure injuries had developed. -Prior to that she had a regular pressure relieving mattress and repositioning every two hours like all residents. *She applied new [MEDICATION NAME] dressings to both heels. *When asked to stage or identify those areas currently she: -Said they were scab-like areas now. -Would not answer what stage they were currently. --She stated she would have to look them up but they started as deep tissue injuries. *RN [NAME] thought the resident should have been wearing heel boots at all times. -That was listed on the nurse treatment administration record (TAR) for them to check placement. *CNA I was still in the room and stated she thought the boots were just when the resident was in bed. *When asked about the resident's compression stockings she stated the resident probably should not have been wearing them but she was not sure. -CNA I confirmed the CNA cheat sheet said for the resident to wear the left leg stocking only. *All three staff confirmed there was a lack of communication and collaboration for the resident's intervention between what the nurse's expectations were and what the CNA expectations had been. *The CNA cheat sheet was again reviewed with the nurses and CNA and they confirmed there was no mention of the resident's pressure injuries or foam boots. Continued interview and record review with LPN D at the nurse's station regarding resident 41 revealed:*He confirmed the TAR had the nurses checking that the resident was wearing the foam boots at all times. -He agreed she had not been wearing the boots that morning. *Review of the resident's last signed 2/27/18 physician's orders [REDACTED]. -Place [NAME] hose (compression stocking) on left lower extremity was started on 1/20/18. -The [MEDICATION NAME] dressing changes to her left and right heel suspected deep tissue injuries were supposed to be checked every day and changed every three days and as needed. --Those treatments started on 2/20/18. *He confirmed her orders had not been followed for her foam boots, the [MEDICATION NAME] dressings, or the compression stockings. *He thought the resident may have removed the dressings herself but the CNAs should have known to contact the nurse to replace them. -If a dressing change was completed that should have been documented on the TAR for proof of the change. *Review of the resident's (MONTH) (YEAR) TAR entries: -The [MEDICATION NAME] daily and PRN entries were started on 2/20/18 and showed no indication of when the dressings were actually changed. --He confirmed that finding and stated there should have been a way to know when they were changed. -There was an entry to check bruise on Left great toe end for breakdown until resolved that was started on 1/22/18. -There was an entry to Monitor blister area Right great toe end. Check Q (every) day. every day shift for monitor that was started on 2/26/18. *Review of the resident's 3/13/18 care plan with LPN D revealed:-There was no mention of her order for the left compression stocking only. -Her care plan had not been followed for her foam boots or the dressings to her heels. *While reviewing the record and discussing that mornings interviews and observations this information confirmed the deficiency. Observation on 03/13/18 at 02:00 p.m. of resident 41 in the lobby area revealed she was not wearing the heel boots again. She was only wearing her small slippers. Observation on 03/13/18 at 03:06 p.m. of resident 41 being wheeled in her wheelchair by staff from the lobby area to the dining room revealed she was not wearing the heel boots. She was not wearing either compression stocking and had her small slippers on. Observation on 03/13/18 at 03:54 p.m. of resident 41 in her wheelchair in the hallway revealed: *She was propelling herself a little in the wheelchair. *The foam boots were on her feet. *Her mood appeared anxious and she was reaching for the boots. Observation on 03/14/18 at 01:10 p.m. of resident 41 revealed:*She was sitting on the edge of the bed in her room. *An unidentified staff member was charting on a kiosk in the hallway outside her room. *She had no foam heel boots on her feet. -She was not wearing socks or shoes. *The foam heel boots were sitting on the chair in the corner of her room. *She was attempting to peel off her left heel dressing. Observation and interview on 03/14/18 at 01:21 p.m. with LPN A and RN G during resident 41's dressing changes revealed:*LPN A was a traveling nurse and had been working in the facility for about one month. *RN G had been working in the facility for about one year. *They removed her previous dressings and applied new FoamLite dressings to both her heels. -It was unclear if a FoamLite dressing was the same thing as an [MEDICATION NAME] dressing. -[MEDICATION NAME] dressing was the product listed on her physician's orders [REDACTED]. *The surveyor asked the nurses about the current staging of her pressure injuries on her heels. -Neither would answer and stated they would have to look at her record. *RN G indicated the resident's pressure injuries occurred after she had a fall and broke her arm. -She had been in bed a lot more after that fall. *She liked to sleep on her back frequently. *RN G stated they did have staff repositioning her more frequently after she returned from the hospital but she was unsure if that would have been documented. *They thought her heel boots were only supposed to be on when she was in bed. -They were not aware they had been ordered for all times. *LPN A thought the resident was supposed to wear compression stocking to both her legs. -She was not aware it was only ordered for her left leg. *Both nurses thought the compression stockings should have been on hold due to her pressure injuries. *They agreed preventative interventions should have been in place prior to a resident getting pressure injuries. -Pressure relieving interventions should have been individualized based on the resident's need. *They confirmed her risk of skin breakdown increased when she had a change in her condition and had spent more time in bed than before. -Her pressure relieving interventions should have been changed related to her decline in condition prior to the development of facility acquire pressure injuries. *They stated RN [NAME] was the nurse who oversaw the pressure areas in the facility. -RN [NAME] did the skin assessments weekly for those areas. *The nurses should have done the daily monitoring of the pressure areas and documented that monitoring. *Both nurses confirmed there was no specific place they documented when the dressings were changed. -The nurses just put their initials in the TAR entries once per shift. -It would have been difficult to track when or if the dressings were changed with the current documentation on the TAR. Interview on 03/14/18 at 03:05 p.m. with the administrator, director of nursing (DON), Minimum Data Set (MDS) assessment coordinator, and social services coordinator S regarding resident 41 revealed: *They confirmed the resident had developed facility acquired pressure injuries. *All residents should have been repositioned every two hours and all the mattresses were pressure relieving. *They confirmed there was a lack of consistency and collaboration between the nurses and CNAs with the resident's pressure ulcer treatments and interventions. -There should have been better communication and collaboration. *They agreed her physician's orders [REDACTED]. *The resident had a decline in her condition overall which increased her risk of skin breakdown. *They agreed her pressure relieving interventions should have been re-evaluated and changed related to that change in condition. -That should have been done prior to the development of her pressure injuries. *During that interview the surveyor requested copies of her Braden assessments, wound assessments, and progress notes related to skin due to the lack of access to the resident's electronic medical record. -Refer to F867, finding 2. *The DON printed the Braden Scale for Predicting Pressure Sore Risk for the resident. -Review of those assessments indicated she was scored as: -Low risk on 8/1/17, 8/7/17, 8/8/17, 8/15/17, 8/22/17, 9/27/17, 10/4/17, 10/18/17, and 11/5/17. -High risk on 2/19/18, which was the day the pressure injuries were noted. -They confirmed the above information. Interview on 03/15/18 at 09:36 a.m. with physical therapy assistant C regarding resident 41 revealed:*She had worked in the facility for about four months. *The resident had not worked with therapy during that time frame. *After the resident broke her arm she was screened by therapy and not picked up for services. *She confirmed the resident had a decline in her condition from her previous level of function. Observation on 03/28/18 at 9:20 a.m. of resident 41 in her room revealed:*She was laying in bed on her back. *She was not wearing the foam heel boots. -They were sitting in the chair in the corner of her room. *Her physician's orders [REDACTED]. Review of resident 41's Pressure Ulcer PUSH Tools that were done weekly by RN [NAME] from 2/19/18 through 3/15/18 revealed: *The scores worsened from a two to four on her left heel and from a one to three on her the right heel. *There was no mention of her toe areas. Interview on 03/27/18 at 01:33 p.m. with RN [NAME] regarding the PUSH Tools revealed: *She did not really look at or do anything with those PUSH scores. *She was directed to just do the PUSH Tool weekly. Review of the telephone physician's orders [REDACTED]. *On 2/19/18: -1. Foam boots on at all times to both feet. -2. [MEDICATION NAME] gentle to L heel suspected deep tissue ulcer (check) QD (everyday) (triangle sign for change) Q (every) 3 days/PRN (as needed) - resolved. -3. [MEDICATION NAME] gentle to R heel suspected deep tissue ulcer (check) QD (change) Q 3 days/PRN - resolved. --The order was written by RN [NAME] on 2/19/18 and was signed by the physician on 2/22/18. *On 2/26/18 monitor blister area to R great toe end (check) QD. -That was written by RN [NAME] and signed by the physician on 2/27/18. *There was no telephone order for the left great toe area. *A 3/13/18 telephone order was written for the foam boots to be on only when in bed after the surveyor had questioned staff about the boots. Interview on 03/27/18 at 01:33 p.m. with RN [NAME] regarding the above telephone orders revealed: *She just wrote up the orders for the skin treatments when a new area was found. -Those orders were then sent to the doctor to be signed. *There was no specific skin guidelines or protocol for nursing to reference for what kind of treatment should have been started. *The [MEDICATION NAME] was one they used a lot and she thought it worked well. Review of resident 41's physician's progress notes from her admission on 8/1/17 through 3/15/18 revealed: *There was no mention of pressure injuries until the 2/27/18 note. That note stated: -She has developed some superficial pressure sores on both heels. - .Heel sores are covered with [MEDICATION NAME] border. --[MEDICATION NAME] which was the ordered treatment was not mentioned. Review of resident 41's last signed 2/27/18 physician's orders [REDACTED].*To Check bruise on left great toe end for breakdown until resolved every day shift. -Order was started on 1/22/18. *Daily pressure ulcer L heel monitoring under assessments tab until resolved every day shift.-Order was started on 2/20/18. *Daily pressure ulcer R heel monitoring under assessment tab until resolved every day shift. -Order was started on 2/20/18. *Foam boots at all times to both feet every shift for unstageable ulcer. -This is the first time the areas were listed as unstageable. --Other documentation listed them as suspected deep tissue injuries. -Order was started on 2/19/18. *[MEDICATION NAME] Gentle to Left heel suspected deep tissue ulcer. Check Q day, change Q 3 days/PRN till resolved as needed for wound care be sure to chart all dressing changes in PCC. -Order was started on 2/20/18 *[MEDICATION NAME] Gentle to Left heel suspected deep tissue ulcer. Check Q day, change Q 3 days/PRN till resolved every day shift for wound care be sure to chart all dressing changes in PCC. -Order was started on 2/20/18. *There were two entries for [MEDICATION NAME] for the right heel suspected deep tissue injury that were the same as the left. -Both orders were started on 2/20/18. *Place TED hose on left lower extremity every day shift for inflammation -Order was started on 1/20/18. *Regional Health Pressure Ulcer Pressure Ulcer Push tool (under assessments) R heel to be completed q Monday with skin assessment measurements every day shift every Mon for wound day. -Order was started on 2/20/18. -There was an identical entry for the left heel. *Skin care per facility protocol as needed. -Order was started on 11/5/17. *Weekly skin assessment to be completed on Mondays every day shift every Mon. -Order was started on 12/14/17. *There was no mention of any skin concerns to her back of her head, buttocks or right great toe. Review of resident 41's Skin Integrity Assessment Records from admission through 3/15/18 revealed: *There was no mention of pressure injuries until the 2/19/18 one which listed: -A suspected deep tissue injury to her right heel measuring 0.5 cm by 0.5 cm. -A suspected deep tissue injury to her left heel measuring 0.7 cm by 0.7 cm. -An other area to the back of her head measuring 5.5 cm by 5.5 cm that said monitor pink blanchi. -An other area measuring 1.0 cm by 8.0 cm that states both buttock and discolored pink area. -Further documentation for the left heel dark area description of: --non-blanching dark area with surrounding pink blanching tissue, foam boots applied. will have daily pressure ulcer charting and push score to be done q week on Monday. EHOB on bed. -Further documentation for the right heel ulcer of: --dark area surrounded by 0.7 by 0.8 white tissue that is not fluid filled or boggy. *On 2/26/18 listed: -The suspected deep tissue injury to her right heel measuring 0.7 cm by 0.7 cm. --That was larger than the week before. -The suspected deep tissue injury to her left heel measuring 1.0 cm by 0.7 cm. --That was larger than the week before. -The back of her head and both buttocks areas had no measurements. -Further documentation for the left heel was faint darker area on back of left heel. no bogginess noted. no drainage. [MEDICATION NAME] gentle with foam boots are on. -Further documentation for the right heel was faint dark area. no drainage. no bogginess. callous like area below. *On 3/5/18 listed: -The suspected deep tissue injury to her right heel measuring 0.8 cm by 1.0 cm. --That was larger in size again. -The suspected deep tissue injury to her left heel measuring 1.3 cm by 1.0 cm. --That was larger in size again. -The back of her head and both buttocks had no measurements. -Further documentation for the left heel was continues to be a dry tan scab like discolored area. will monitor. -Further documentation for the right heel was tan scab like area. no drainage. no bogginess. callous like area below that is 1.5 by 1.0. *On 3/21/18 listed: -The suspected deep tissue injury to her right heel measuring 0.5 cm by 0.7 cm. --That was slightly smaller. -The suspected deep tissue injury to her left heel measuring 1.2 cm by 1.0 cm. --That was slightly smaller. -There was no mention of the back of her head or buttocks areas. -Further documentation for the left heel was continues to be a dry brown scab like discolored area. will monitor. -Further documentation for the right heel was brown scab like area. no drainage. *There was no mention of areas of concern on her toes. Interview on 03/27/18 at 1:33 p.m. with RN [NAME] regarding the above Skin Intergrity Assessment Records revealed: *Those were her weekly wound assessments. *She did those weekly assessments on Mondays. *She confirmed the areas appeared to be getting large for the first two weeks after they were noted. *When asked about potentially changing treatments or notifying the physician she indicated they had no protocol of when that should have been done. -She thought the areas were getting better now though so the treatment was working. *When asked how she decided to stage them as suspected deep tissue injuries she stated it was because they appeared to be when they first were noted. -She stated they might have been unstageable areas now. -She thought if the scabs came off of them there would be nothing underneath. *She confirmed the toe areas had not been measured or assessed weekly and could have been pressure injuries. -She had put an order on the TAR for the nurses to monitor them daily. *She stated she usually focused on pressure injuries only during her weekly assessments. Review of resident 41's Pressure Ulcer/Stasis Ulcer Daily monitoring records from 2/19/18 through 3/15/18 revealed:*They were not completed daily. *Forms were completed only on the following dates: -2/19/18. -2/21/18. -2/22/18. -2/26/18. -3/5/18. -3/12/18. -3/14/18. *According to these forms the physician was only notified on 2/19/18 even though the measurements got larger for both heels. *There were no records for the areas on her toes. Interview on 03/27/18 at 01:33 p.m. with RN [NAME] regarding the above Pressure Ulcer/Stasis Ulcer Daily Monitoring forms revealed: *They should have been completed daily by the charge nurses. *She confirmed there had been several days that were not done. *She agreed they had not mentioned the areas on her toes. *The resident's TAR directed the nurse to complete these daily. -The nurses had signed on the TAR that these were getting done daily but the records proved otherwise. Review of resident 41's interdisciplinary progress notes from her admission on 8/1/17 through 3/15/18 related to her skin revealed: *On her admission on 8/1/17 there was no mention of pressure ulcers or her risk of skin breakdown. -The note stated .Skin has numerous bruises and [MEDICAL CONDITION] . *There were injuries related to falls to her skin from admission through 3/15/18 that included bruising, skin tears, or other lacerations. *On 1/22/18 Left great toe assessed and toe blanches with small bb sized spot of light dusky bruise noted at tip. No boggy tissue, vesicle or pressure area noted. Will monitor with daily check tx at this time. -Unsure if this was the same area as noted during the observation on 3/13/18. *On 1/24/18 resident was sent to hospital for ultrasound of left lower leg and found to have a [MEDICAL CONDITION]. *After her fall on 1/31/18 where she fractured her arm there were notes indicating she: -Was in bed or sleeping more than before. -Was not eating as well, was seeing speech therapy, and had diet order changes. -Had pain related to her fracture. *There was no mention of skin concerns until 2/19/18. *On 2/19/18: -The nurse note stated resident skin checked during bath upon assessment multiple skin discolorations were found on back of head, both heels, and couple areas on bilateral buttocks all were measured and recorded. new mattress in now in place, boots were applied and cream to the bottom was applied family was notified. -The dietitian note stated Resident noted as having unstageable areas to both heels. Intake at meals has been *On 2/20/18 the dietitian note stated The area is suspected deep tissue injury not open. Discontinue the [MEDICATION NAME] Extra. -There was no: --Note by nursing that day. --Indication of why the [MEDICATION NAME] supplement would not be recommended for a suspected deep tissue injury. *On 2/21/18: -At 12:46 p.m. a nurse note Dressings changed to heels and they were off. no drainage or open area noted on heels r/t suspected deep tissue wounds. See charting under assessments tab. -At 12:52 p.m. a nurse note Dressing changes to back of both heels this am as dressings off. No change in condition of wounds. Foam boots do not stay on feet well as resident moves feet back and forth. Will continue to tx. --Both those notes were by the RN E. *On 2/26/18 was the next note by the RN [NAME] and stated: -Informed per primary nurse to check (resident's) right great toe. Found blister/soft like area tan/brown in color that is 1.3 x 1.0 (1.3 centimeters by 1.0 centimeters) in size. Wears only slipper socks and foam boots and is on air bed. Will monitor at this time. Not staged as ulcer. Ulcers on right and left heel were measured today and documentation noted in skin integrity assessment. -There was no mention of a change in interventions related to that new skin concern. *On 3/5/18 by the RN [NAME] stated: -Right great toe previous vesicle is dry and no longer fluid filled. No dressing on toe. Has continued dry scab like areas on back of heels r/t previous purple boggy areas that are pressure related with no drainage. Dressings to heels changed. Back of head continues with same discolored blanching area and shows no regression. Buttocks are clear. -This was the first mention of the buttock areas since 2/19/18. *On 3/12/18 the RN [NAME] nurse stated wound care done to both heel ulcers and noted them to be dry and without change. Both have smaller brown scabs. No redness/drainage. *On 3/13/18 at 6:07 a.m. the charge nurse stated Resident laying in bed supine, eyes closed .Heel [MEDICATION NAME] and boots in place. Will continue to monitor. -There were no further notes from that nurse that day. -In the observations and interview above with that nurse the resident's foam boots and dressing had not been in place. *On 3/13/18 at 9:03 p.m. the nurse stated Resident removing boots, socks, and dressings to her feet. Staff attempts to reapply or distract unsuccessfully. -This was the only documentation related to the resident removing her own dressings and was after the surveyor had questioned the nurse about it. Review of resident 41's 3/14/18 care plan related to her skin revealed:*This was requested to be printed with all the revisions and edits to see the history of the interventions. *There was no mention of the areas of concerns to the back of the resident's head, her buttocks, or left great toe. *The only change in her interventions for skin from her fall on 1/31/18 through the development of her pressure injuries on 2/19/18 was to: -Ensure that the steri strips on my forehead remain clean dry and intact. Keep dressed/treated as prescribed. *After the pressure injuries to her heels were identified on 2/19/18 interventions were added for: -I have an EHOB (name brand) on my bed, I am to be repositioned q 2 hours and I wear foam boots at all times. -I will have dressing changes to my heel ulcers per orders with daily and weekly charting per orders until resolved. --According the above record review and observation the orders and daily charting orders were not followed. *She had another focus area related to her left leg [MEDICAL CONDITION]. -That had not mentioned her order to wear [NAME] hose to her left leg only. -During the observation on 3/13/18 she was wearing [NAME] hose to both legs and the physician's orders [REDACTED]. Continued interview on 03/27/18 at 01:33 p.m. with RN [NAME] regarding resident skin concerns revealed: *She did not want to be called the wound nurse she was just the nurse who did the weekly measurements on pressure injuries. *She confirmed the documentation for skin concerns and pressure injuries was incomplete and unclear. *She stated she had no formal training for pressure injuries other than a webinar after last year's survey. *She had been the nurse overseeing wounds during the previous recertification survey in (MONTH) of (YEAR). -She was aware of the concerns the survey had identified with pressure injuries at that time. *She agreed individualized pressure injury prevention interventions should be implemented prior to pressure injuries developing. *Residents' care plans should be updated with those interventions and followed by the staff. *physician's orders [REDACTED]. *The resident's physician's should have been updated: -On any new pressure injuries. -Periodically on existing pressure injuries if they worsened or were not improving. *The provider had general physician's standing orders that stated Skin care per facility protocol. -There was no specific guidelines for the nurse to implement a specific treatment. *She indicated the nurse would decide on a treatment, write the telephone order, and send that order for the physician to sign. 2. Observation on 03/12/18 at 05:17 p.m. of resident 53 revealed: *He was very thin with a small body frame. *His skin appeared thin and fragile. *He was sitting in high back wheelchair in his room with his eyes closed. -The wheelchair appeared to have a cushion in it but it was difficult to see with him sitting in it. *His bed had an air mattress on it. Review of the revised 3/12/18 facility resident matrix edited by the DON indicated resident 53 had been admitted with skin concerns. Review of resident 53's medical record revealed: *He was admitted on [DATE]. *He had short and long term memory problems. *His [DIAGNOSES REDACTED]. *Review of his hospital transfer record indicated he had skin concerns to both feet and legs. -[DIAGNOSES REDACTED]. *He was dependent on staff to: -Anticipate his care needs. -Assist with his activities of daily living. *His 2/15/18 admission physician's progress note indicated: -He had a history of [REDACTED]. | 2020-09-01 |