| 161 |
HABERSHAM HOME |
115099 |
HIGHWAY 441 NORTH, BOX 37 |
DEMOREST |
GA |
30535 |
2017-05-18 |
314 |
D |
1 |
1 |
KH1211 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review and staff interview, the facility failed to use the correct wound care product as ordered, and failed to consistently do weekly skin assessments for one resident (R) #24, who was high risk for skin breakdown and currently had an unstageable pressure ulcer. The sample size was 37 residents. Findings include: 1. Review of R #24's clinical record revealed that he was admitted to the facility with [DIAGNOSES REDACTED]. Review of labs dated 4/7/17 revealed that he had an [MEDICATION NAME] level of 2.3 (normal 3.5-5.0). Review of a Braden Scale done on 5/15/17 revealed that he was assessed as high risk for skin breakdown. Review of a physician's orders [REDACTED]. Review of a Weekly Pressure Assessment Tool dated 4/5/17 revealed that the resident was readmitted to the facility that day with a Stage 3 sacral pressure ulcer. Review of his 30-Day Minimum Data Set ((MDS) dated [DATE] noted that he had severe cognitive impairment, was a pressure ulcer risk, and had one Stage 3 and one unstageable pressure ulcer. Review of physician's orders [REDACTED]. Review of Physician's Progress Notes dated 5/9/17 noted the resident continued to decline, and his Stage 3 sacral decubitus was not getting better. During observation of wound care to R #24's sacral wound performed by the Director of Nursing (DON) on 5/17/17 at 9:07 a.m., grayish-black eschar was noted in the wound bed, and the wound bed was dry. The DON was observed to clean the wound with wound cleanser, packed the wound bed with [MEDICATION NAME] Ag Extra, and covered the wound with a [MEDICATION NAME] dressing. During interview with the DON at this time, she stated that the [MEDICATION NAME] was used to help get rid of the slough, and to absorb moisture in the wound. Review of Weekly Pressure Assessment Tools dated 4/12/17 and 4/18/17 revealed that the wound had no drainage. Review of a Weekly Pressure Assessment Tool dated 5/4/17 revealed that the sacral pressure ulcer present on readmission as a Stage 3 was now unstageable and contained 100% slough. Further review of this Assessment noted that there was no drainage, and the wound progress was worse. During interview with the DON on 5/18/17 at 1:35 p.m., she verified that she used [MEDICATION NAME] Ag Extra instead of [MEDICATION NAME] Ag as ordered when she performed the wound care on 5/17/17, and stated that the Extra form of the product was all that was available on the treatment cart. During interview with Registered Nurse (RN) II at this time, who was the usual wound care nurse, she stated she thought that the Extra on the package labeling meant that the dressing was a larger size, not that it had any different properties than [MEDICATION NAME] Ag. During interview with RN II on 5/18/17, she stated that [MEDICATION NAME] Ag Extra was intended to be used for moderate to heavily-draining wounds, and was not the same product as [MEDICATION NAME] Ag, which was intended for light to moderately-draining wounds. Review of the facility's Dressing Changes policy revised (MONTH) 2007 noted that for a clean dressing change procedure, refer to treatment record and orders. Apply the appropriate dressing and secure. Review of the website of the manufacturer of [MEDICATION NAME] products revealed: [MEDICATION NAME] Ag Extra wound dressing is nine times stronger and has 50% greater absorbency as compared to the original [MEDICATION NAME] Ag wound dressing. 2. Review of R #24's Body Audit Forms since readmission to the facility on [DATE] revealed that skin assessments were done on 4/10/17 and 4/17/17, but none were found from 4/17/17 to 5/18/17. During interview with the DON on 5/17/17 at 9:25 a.m., she stated that the wound care nurse did the weekly skin assessments on all residents. During interview with RN II on 5/18/17 at 3:05 p.m., she stated that she was not able to find any other weekly skin assessments past 4/17/17 for R #24. She further stated that she was the one responsible for doing the skin assessments, but that she had not been able to do them lately because she was assigned to work on a med cart. During an observation of a skin assessment performed by RN II on R #24 on 5/18/17 at 3:21 p.m., the resident's feet were noted to be extremely dry and flaky, and a purplish area of skin was observed on his left lateral foot below the fifth toe. During interview with RN II at this time, she stated that she was not aware of this area, but the purplish area disappeared when the flaking skin in the area was removed. Review of the facility's Documentation of Treatments policy revised (MONTH) of 2009 noted: In order to assure proper monitoring and documentation of the condition of each resident's skin integrity, weekly assessments will be performed by a licensed nurse. |
2020-09-01 |