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32 | R1 was admitted to the facility on October 3, 2016 from Post-Acute Care Center (hospital). According to R1’s spouse, prior to admission R1 was able to walk by using a walker. According to R1’s Physician Report, dated September 29, 2016, there was no history of skin condition or breakdown. Home health agency made 6 visits between October 5, 2016 and November 12, 2016. There was no mention on their notes of any wound during this period. Specifically, on November 2, 2016 and on November 15, 2016, the notes indicate that there was a skin assessment. Skin was intact and no pressure ulcers were noticed.
The investigation revealed that on November 22, 2016, according to the Facility’s Daily Shift Note, a pressure injury was observed on R1’s ankle and an x-ray was ordered by R1’s PCP on November 23, 2016. The facility staff attempted to schedule an x-ray, however the facility staff was not successful and failed to follow-up on scheduling the x-ray. Based on the caregiver statements and medical records, the condition of R1’s ankle changed between November 22, 2016 and November 26, 2016, and facility staff did not seek further medical attention. On November 26, 2016, R1 was sent to the ER for treatment. At that time, the heel wound was determined to be an unstageable, suspected deep tissue injury measuring at 6.8 cm with unknown depth, ruptured blood blister with maroon purple wound bed. According to the National Pressure Ulcer Advisory Panel (NPUAP), unstageable pressure injury is defined as full thickness tissue loss in which the bade of the ulcer is covered by slough (yellow, tan, gray, green, or brown) and /or eschar (tan, brown or black) in the wound bed. It was also determined that R1 had two stage 2 pressure injuries on R1’s right ankle (2.5 x 2.5 cm). NPUAP defines stage 2 pressure injury as partial thickness loss of dermis presenting as a shallow open ulcer with red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister (https://npiap.com/page/PressureInjuryStages).
Facility Daily Shift Note dated November 24, 2016 (p.m. shift) also indicated a sore on the back was observed. However, there is no record of reporting the sore on the back to R1’s family or PCP. This sore later developed to a stage 2 coccyx wound (8 x 2.5 x 0.2 cm). There were no notes in ER records for the November 26, 2016 visit mentioning the “sore on the back.” R1 was discharged back to the facility on the same day with an order for Home Health Agency (HHA) to provide wound care for the bilateral ankles. On November 28, 2016, December 2, 2016, and December 5, 2016, HHA visited R1 and instructed facility staff to apply barrier cream to the coccyx area.
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