The resident died on June 14, four days after her family was finally notified of the wounds.
Federal inspectors found that Diamond Care Center failed to provide necessary pressure ulcer care to two residents during a June complaint investigation. The facility terminated two licensed practical nurses following the incident and provided abuse and neglect education to all staff, according to administrator interviews.
Hospice registered nurse L discovered the neglect on June 10 when she contacted interim director of nursing G about the resident's deteriorating condition. The nursing director admitted that staff had simply placed the resident in her wheelchair and applied cream to her buttocks instead of using the specialized foam dressings hospice had provided three days earlier.
"She had a history of just being pushed to the side and she was very disappointed in the provider's management of her pressure ulcers," hospice nurse L told inspectors.
The resident had been admitted to hospice care in January. On June 6, hospice certified nursing assistant K found her "soaking wet with urine although she had a catheter in place" and discovered the initial redness on her buttocks. Two areas appeared on the right buttock, "about as long as her thumb" with another "higher up by her butt crack and a little longer than the first one."
Hospice nurse K immediately notified her supervisor and was instructed to alert the facility's nursing staff. The next day, June 7, hospice nurse H brought Optifoam dressings to the facility and gave them directly to licensed practical nurse I, asking that they be applied once the resident was back in bed.
But the dressings were never used.
When hospice nurse L returned on June 10, licensed practical nurse J told her "that the Optifoam was not applied over the weekend and did not think that resident 1 had been repositioned." The wounds had worsened dramatically during those three days of neglect.
Hospice certified nursing assistant K described being "disturbed and astounded by the change in the appearance of her buttocks" when she saw the resident on June 10.
The resident's daughter came to the facility that day, took photographs of her mother's wounds, and sent them to hospice nurse L, who identified at least one area as a Stage III pressure ulcer involving full thickness skin loss.
By June 11, when staff finally completed a wound assessment, they documented six separate pressure areas: two on the left buttock measuring 6.0 by 8.0 centimeters and 2.5 by 2.0 centimeters, two on the right buttock measuring 7.0 by 7.0 centimeters and 1.5 by 1.5 centimeters, one on the tailbone measuring 1.7 by 0.8 centimeters, and one on the left heel measuring 2.9 by 2.0 centimeters.
The family requested an air mattress for the resident's bed, which hospice ordered. A physician was notified and wound care orders were entered. The first documented application of the Optifoam dressing occurred on June 12 - five days after hospice had provided the supplies.
A second resident at Diamond Care Center developed seven pressure ulcers while under the facility's care, including wounds that worsened from Stage 2 to Stage 3 and multiple areas requiring antibiotic treatment for infection.
Resident 4 had been admitted in August 2023 with Alzheimer's disease, diabetes, and other conditions that left her dependent on staff for all aspects of care. She was admitted to hospice in February 2024.
Her first pressure ulcer appeared after a fall on December 3, 2023, when a nurse heard "a loud noise" and found her sitting on the floor near her sink with "some blood coming from a spot on her right outer ankle."
On December 28, the director of nursing documented discovering "a new pressure injury to her right ankle" during a bath assessment. The wound progressed from a Stage 2 to Stage 3 pressure ulcer over the following months.
By March 4, she had developed a second wound - a deep tissue injury described as "dark purple in color" and "pea-size" on the lateral edge of her right foot. Four days later, the ankle wound "appears larger and now measures 3.1 by 2.5 by 0.4" with "a small necrotic dark area."
By March 9, both wounds had signs of infection. A nurse documented that the ankle wound "appears swollen and red and warm to the touch" with "100% green/yellow slough" and increased necrotic tissue. The physician ordered antibiotics.
Additional pressure areas continued developing. On April 11, the director of nursing found "an open pressure area to her left buttock/sacrum." Three days later, nurses documented "a large fluid filled blister to lateral left heel and a medium sized blister to the medial left heel" along with worsening infection in the ankle wound, which had "foul smelling drainage" and was "bright red, swollen and warm to touch."
The physician ordered a second antibiotic.
On April 15, nursing staff and hospice decided to discontinue all wound care and provide comfort care due to poor circulation. But three days later, the physician advised continuing wound care to the ankle to "maintain current status."
Despite having multiple pressure ulcers for months, the facility didn't complete a comprehensive skin and positioning evaluation until April 28 - the first documentation that pressure-relieving approaches and a turning and repositioning program had been implemented.
The resident's care plan wasn't updated to reflect her pressure ulcers until April 28, four months after her first wound developed. Even then, the plan didn't include all seven pressure areas that had been documented in her progress notes.
Her "closet care plan" - instructions placed in residents' rooms for nursing assistants - wasn't updated for five months. The January version listed her only special need as oxygen, with no mention of pressure ulcer prevention or wound care. The updated June version finally included "heel boots/gripper sock at all times" and noted she should be "repositioned on rounds" and provided with "offloading," though it didn't specify what should be offloaded.
During the inspection, the MDS coordinator told investigators the documentation of resident 4's pressure ulcer care "was difficult to follow" and promised to organize a timeline for review. The next day, she admitted she "had not put together the documentation of the timeline of the pressure ulcer care."
The coordinator explained that hospice couldn't provide an air bed because the resident didn't meet guidelines, and the facility was reluctant to provide one because "she was scared the resident would break a hip because she moved in bed." The resident initially used her own mattress when pressure ulcers started, later accepting a facility pressure-relief mattress.
She described the resident's habit of placing her feet sideways against the mattress when lying in bed, which the coordinator believed contributed to the pressure ulcers.
Inspectors observed the resident on multiple days wearing small foam boots but noted "no other pressure-relieving measures were in place" when she was lying in bed.
The facility's pressure ulcer prevention policy states its purpose is "to promote the prevention of pressure ulcer development" and "to prevent the development of additional pressure ulcer." The policy requires providing "necessary treatment and services to a resident having pressure sores to promote healing, prevent infection and prevent new sores from developing."
Administrator A told inspectors that the facility's expectation would have been for pressure ulcers to be "checked on daily and documented in the resident's EMR." The facility's charting policy warns that skipping rounds "can be considered neglect."
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Diamond Care Center from 2024-06-21 including all violations, facility responses, and corrective action plans.