The incident at Elevate Health and Rehabilitation triggered immediate jeopardy violations during a federal inspection in August, along with separate findings that staff failed to follow up on critical kidney stone surgery orders for another resident.
The treatment aide used a Coban 2 two-layer compression system instead of regular Coban wrapping during wound care for Resident #31, who had diabetic foot ulcers. The compression system is designed for venous leg ulcers and lymphedema, not diabetic wounds.
Federal inspectors watched the July 24 procedure. After applying the compression wraps to both feet, all of Resident #31's right foot toes turned dark purple. The aide didn't check circulation before leaving the room.
When inspectors asked about the purple color, the aide returned to check. "Resident #31's toes were not normally purple and the dressing was too tight," she told inspectors. After removing the compression layers, his toes returned to normal color.
The left foot showed dusky gray skin discoloration when the dressing came off the next day, with a small maroon-purple spot on top of the foot that didn't blanch when touched.
The aide explained she thought the compression system was correct because the box was labeled "Coban2" and her orders called for Coban. She had never used the compression system before on this resident.
"The Treatment NA stated she had not applied the Aquacel that was part of his treatment orders, because the facility had been out of Aquacel for two weeks," inspectors wrote.
The podiatrist treating Resident #31 never ordered compression wraps. "She said compression wraps were for patients with venous ulcers or who had a lot of swelling, and that Resident #31 did not have any of that and compression wraps were not appropriate for him."
If the tight dressing had remained until the next scheduled change two days later, it could have caused circulation problems, vessel blockage or new wounds, according to the facility's medical director.
The treatment aide also discovered a new wound on Resident #31's right heel but treated it with iodine for over a week without getting orders from a physician. She said the unit manager told her to use iodine, but the unit manager denied this conversation.
The podiatrist learned about the new heel wound only during a July 22 office visit, weeks after it appeared. "The Podiatrist stated that if the facility had notified her, she would have given treatment orders for the right heel."
In a separate case involving the same treatment aide, she applied wrong treatments to another resident's pressure ulcers. For Resident #3's coccyx wound, she used collagen powder instead of the ordered calcium alginate and diluted bleach solution. For the back wound, she applied honey instead of the calcium alginate and bleach solution.
The aide told inspectors she was "overwhelmed and could not remember everything" and was "nervous about being watched and did a very bad job."
The facility's most serious violation involved a complete breakdown in following up on specialist appointments. Resident #53 had been hospitalized in April for kidney stones that caused sepsis and required emergency stent placement. His discharge orders specified follow-up with urology within one to two weeks for surgery to remove the stones.
Staff transported Resident #53 to his urology appointment on May 16. The urologist ordered a CT scan and follow-up appointment to schedule surgery for stone removal and stent exchange. The nursing assistant who accompanied him returned with written instructions.
Nobody at the facility followed through.
The medical director and nurse practitioner continued noting in progress reports that Resident #53 needed urology follow-up. The resident suffered ongoing blood in his urine for months, receiving multiple courses of antibiotics despite negative urine cultures.
"The Medical Director stated he expected the staff to notify the wound care provider of new wounds or that they could notify him if unable to reach the wound care provider, so new wound care orders could be given."
The urology office practice manager confirmed they received no follow-up from the facility. The CT scan order remained unused in their system until July 18, when staff finally requested a new appointment due to continued bleeding.
"She revealed this information was verbally discussed with Resident #53 and the facility staff that accompanied him to the visit and provided in writing as part of the office note given to the facility staff on that day."
The nursing assistant who accompanied Resident #53 to the May appointment said she gave the paperwork to nursing staff when they returned. But the nurse working that hall said he never received any urology paperwork or CT scan orders.
The facility's transportation scheduler, who started in July, said she received no orders to schedule urology appointments for Resident #53 until July 18.
Multiple staff members, including the medical director and nurse practitioner, told inspectors they repeatedly requested urology consultations but were told appointments were "pending" or "in process."
The urologist explained that delays in stone treatment increase infection risks with indwelling stents. Resident #53's CT scan, finally completed July 30, showed a 13-millimeter stone in his right kidney and multiple stones in his left kidney.
In other violations, inspectors found a treatment aide left confidential medical information visible on an unattended computer screen in the hallway. The screen showed a resident's name, photo, medications and private health information accessible to anyone passing by.
The aide said she was distracted by a call light and forgot to activate the privacy screen. She had received HIPAA training months earlier.
Inspectors also found inaccurate smoking assessments for two residents. One resident's assessment showed he was an independent smoker despite being supervised due to previous incidents of hiding vapes in his room. Another resident hadn't received required quarterly smoking assessments since admission over a year earlier.
The facility removed immediate jeopardy status on July 27 after implementing new procedures requiring licensed nurses to perform all wound care and establishing systems to track specialist appointments and follow-up care.
Staff received education on differentiating compression systems from regular wraps, and the facility removed all Coban 2 compression systems from treatment carts to prevent confusion.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Elevate Health and Rehabilitation from 2024-08-07 including all violations, facility responses, and corrective action plans.
Additional Resources
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