Resident #5, younger than 65 and cognitively intact, entered Hilltop Park Post Acute on November 7, 2023. His admission skin assessment documented intact skin throughout his body. Within 14 days, he had developed an unstageable pressure injury on his tailbone.
By January 2, 2024, the wound had progressed to Stage 4 — full-thickness tissue loss with exposed bone, tendon, or muscle. On June 6, X-rays confirmed osteomyelitis, inflammation of the bone due to infection.
The wound care physician interviewed on July 24 called the pressure injury "avoidable" and said the resident "had no other clinical issues that could contribute to the wounds." He was unaware of any changes in the resident's daily routines that could have contributed to the development or worsening of the pressure injury.
Federal inspectors found the facility failed to provide timely pressure-reducing measures. An order for an air mattress wasn't initiated until February 21, 2024 — seven and a half weeks after the wound was identified as unstageable. The mattress wasn't actually placed until March 10, twenty days after the order was written.
When inspectors interviewed the resident on July 24, he said his current mattress was broken and "the one he had before was worse." The laundry director told him "this was the best mattress she could find."
The facility couldn't verify the age or usage history of the resident's air mattress. The laundry director, who managed mattress placement, said the facility had "several backup pumps in stock" but "most of the air mattresses in stock were older and had been acquired by the previous facility owners."
She said some mattresses "were used more than others and they no longer tracked the age or length of time a mattress was used." The facility lacked manufacturer manuals for the mattresses and "did not know the exact age of the mattresses in stock."
The resident told inspectors staff didn't reposition him at night unless he asked. "At night, they do not come in and reposition him unless he asks them to," according to the inspection report.
His care plan didn't include instructions for staff to help with turning and repositioning until January 3, 2024 — about a month after the wound was identified and after it had progressed to Stage 4.
The facility's pressure injury prevention policy required repositioning "all residents with or without risk of pressure injuries on an individualized schedule" and choosing "a frequency for repositioning based on the resident's risk factors."
Weekly skin assessments were routinely missed. No assessments were completed on March 7, March 14, April 3, April 17, May 2, May 23, or June 27, according to inspection records.
Wound care orders weren't followed. A June 21 order specified dressing changes "every other day," but treatment records showed daily changes from June 23 to June 25. Another order from June 26 for every-other-day changes was ignored, with daily changes documented from June 26 through July 2.
During an observed wound care session on July 25, the registered nurse failed to place a barrier pad under the resident during treatment. When interviewed afterward, the nurse acknowledged "she should have placed a barrier pad under the resident during wound care to protect him and the linen from being contaminated" and said "not placing a barrier pad could put the resident at risk for germs to get into the wound."
The resident was ordered a double protein diet on February 13 to support wound healing, but inspectors observed he wasn't receiving it. On July 23, his meal tray was marked "double ham" but the sandwiches contained only one slice of ham. The same occurred July 24.
The registered dietitian consultant confirmed the sandwich "was not double the ham." When she asked if he wanted additional meat, the resident replied "It is a little late" since he had already eaten most of the sandwich.
The wound care physician suspected osteomyelitis when the wound stopped healing and ordered X-rays to confirm the diagnosis. On July 16, a wound culture was collected. Two days later, orders were written for a peripherally inserted central catheter to administer IV antibiotics. On July 19, orders for Cefepime and Vancomycin were initiated for the bone infection.
The nursing home administrator interviewed on July 29 said he didn't recall discussing the resident's wound status and "was not aware that Resident #5's coccyx wound was infected." He said he was "more involved in working with the interdisciplinary team on revamping the overall care and treatment programs for all residents, rather than knowing the individual treatment needs of each resident."
The director of nursing said there was "a lapse in communication from the interdisciplinary team to her" and "the floor nurses did not alert her of Resident #5's wound status in a timely manner." She wasn't immediately aware "that the resident's wound was infected or that the floor nurses were not following wound care orders."
The resident required a minimum six-week course of IV antibiotics to treat the bone infection that developed from what the wound care physician called an entirely preventable pressure wound.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Hilltop Park Post Acute from 2024-07-29 including all violations, facility responses, and corrective action plans.