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Resident sustained pressure wounds while in care- UNSUBSTANTIATED
It was alleged that a resident sustained pressure wounds while in care.
LPA review of home health nursing notes revealed that from the dates of 05/03/2022 – 6/08/2022 No skin issues were noted and R1’s skin was clear at time of assessment by home health nurse. On 6/10/2022 nursing notes stated “Non-Blanchable redness noted to outer right foot. No other skin issues noted.´ On 6/15/2022 nursing notes stated “Skin: at time of assessment, unstageable wound to right lateral foot, wound care performed per MD order. educated staff with positioning of patient to and use of prophylactic equipment (heel booties), to protect the wound bed.”
LPA review of medical records dated 2/15/2022 – 03/08/2022 revealed that R1 had a Braden score of 14-18 during various visits and hospitalizations for that period. Of note in these medical records:
02/24- 3/08/2022 Doctor’s Orders stated that R1 was “at risk (Braden score 15-18) Patient will be turned Q2 hr. Physician ordered for R1 to be encouraged to be as active as possible, heels will be protected, R1 was placed on pressure reduction surface, staff were to manage moisture, nutrition, friction and sheer, and advance to higher level of risk as indicated.
2/25/2022 Consultation note for nutrition evaluation Comment: No wounds/pressure injuries/Ulcers per review of nursing notes dated 2/24/2022. Braden score: 17.
03/01/2022 Braden score: 14 Preventive interventions. Abnormalities/redness. Location: Coccyx and heels.
03/01/2022 Progress notes: Patient is refusing to be floating on pillows and wants to lay on his right side which is red. Educated patient on redness of skin and patient still wants to lay on his right side. All safety measures in place call light within reach.
Medical records revealed that on 03/08/2022 R1 was transferred to Country Crest Post-Acute for rehabilitation.
Continued on LIC9099-C
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