cms_GA: 2472
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rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
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2472 | RIVER TOWNE CENTER | 115566 | 5131 WARM SPRINGS RD | COLUMBUS | GA | 31909 | 2019-10-10 | 686 | E | 1 | 0 | PV5P11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews and record reviews, the facility failed to ensure pressure ulcer treatments and/or assessments were provided and documented consistently for five of seven residents (R#10, R#9, R#2, R#13, and R#12) reviewed for pressure ulcers. Findings include: During an interview on 9/24/19 at 3:20 p.m., Treatment Nurse, Licensed Practical Nurse (LPN) FF stated the she started doing wound treatments at the facility at the end of (MONTH) and had provided treatments as ordered. She further stated that she had problems with documentation in the computer at times. When she provided a treatement, then would click off on it in the computer as being completed, the computer would spin and spin like it was taking a long time to accept/save, and that it happened often. LPN FF also stated that she had problems trying to input orders into the computer on her laptop and would usually have to use the computers at the nursing stations. LPN Treatment Nurse FF was not employed at the facility after 10/2/19. 1. Resident (R) #10 had [DIAGNOSES REDACTED]. In addition, an arterial doppler report, dated 7/6/19 documented moderate stenosis in the arterial system of the left lower extremity. The resident was assessed on the 7/22/19 Quarterly Minimum Data Set (MDS) assessment as having cognitive impairment, being nonambulatory, and ranging from needing extensive assistance to being dependent on nursing staff for Activities of Daily Living (ADL's). A care plan was in place, dated 8/20/19, that included that R#10 had the potential for skin impairment related to weakness and bowel and bladder incontinence with an intervention for nursing staff to monitor and document location, size, and treatment of [REDACTED]. However, nursing staff failed to monitor and document the location, size and treatment of [REDACTED]. R #10 had a pressure ulcer to the left hip that was initially assessed by the wound physician on 9/11/19. The initial assessment documented that the pressure ulcer was a stage 4 and measured 13.8 x 8 x 0.1 centimeters (cm), with 100% thick adherent devitalized necrotic tissue. A review of the clinical record revealed that prior to 9/11/19, weekly skin assessments had been completed on 9/2/19 and 9/9/19. The weekly skin assessments completed on 9/2/19 and 9/9/19 documented that the left and right hip were being treated by the wound nurse. However, there was no evidence in the clinical record or on the facility Skin Integrity Reports of a pressure ulcer assessment or what treatment was being provided for the left hip pressure ulcer before 9/11/19. On 9/11/19 the wound physician ordered Santyl ointment and a dry protective dressing be applied to the left hip pressure ulcer once daily for 30 days. However, a review of the clinical record, including the (MONTH) Treatment Administration Record (TAR), revealed no evidence that the physician ordered treatment was carried out until 9/19/19. After 9/19/19 the wound physician continued to routinely assess R#10's pressure ulcers. The 10/2/19 Wound Evaluation and Management Summary report from the wound physician documented the left hip pressure ulcer as improved, measuring 11.1 x 10.5 x 0.8 cm with 40% thick adherent black necrotic tissue and 60% granulation tissue. On 9/29/19 a Nurse Progress Note timed at 7:41 p.m. documented that the nurse was called to the resident's room at 2:30 p.m. and the nurse noted multiple white insects on the resident's right ankle. The nurse note further documented that a head to toe skin assessment was completed and the resident was transported to the shower and all wounds were redressed. Although the 9/29/19 nurse progress note documents the resident's right ankle, interviews on 10/1/19 at 2:25 p.m. with acting Director of Nursing (DON) BB, who was the previous Assistant DON, and on 10/8/19 at 4:37 p.m. with CNA KK, who were both present on 9/29/19, clarified that the insects were observed on the left lower extremity. A review of the clinical record, including wound physician's notes, physician's orders [REDACTED].#10 had daily dressing changes ordered for pressure ulcers to his lower extremities that included the right heel, top of the left foot, left lateral foot, and left medial foot. However, there was no evidence that pressure ulcer treatments were completed, as ordered, on 9/28/19, the day prior to the insects being found. During an interview on 10/1/19 at 4:45 p.m., the acting Director of Nursing (DON) BB stated that she spoke with LPN JJ by phone and he stated that he, along with a Certified Nursing Assistant (CNA), changed all of the resident's dressings on 9/28/19. During an interview on 10/8/19 at 4:37 p.m., CNA KK stated she assisted LPN JJ when he changed the pressure ulcer dressings to the resident's hips on 9/28/19, but she did not help change the dressings on his feet or see the nurse complete those. R#10 had a pressure ulcer identified to the left medial foot on 8/28/19. The wound physician assessed the pressure ulcer on 8/28/19 and documented it as a 1 x 2.4 x 0.1 cm Stage 3 pressure ulcer with 100% granulation tissue. The wound physician ordered a treatment of [REDACTED]. However, a review of the clinical record revealed no evidence of the treatment order being documented and carried out. A review of the (MONTH) through (MONTH) 2019 TAR's revealed evidence of physician ordered treatments being provided to additional existing pressure ulcers on the left lower extremity, including the left heel (until 8/15/19), left foot, and left lateral foot, but not the left medial foot. A review of the most recent Wound Evaluation and Management Summary report from the wound physician, dated 10/2/19 revealed that the left medial foot wound had merged with another left foot wound that was being treated. R#10 had a 5 x 5 x 0cm pressure ulcer identified to the right heel on 8/30/19. The wound physician assessed the pressure ulcer on 9/4/19 and documented it as a 5.2 x 5.7 cm Unstageable Deep Tissue Injury (DTI). The wound physician ordered [MEDICATION NAME] and a dry protective dressing be applied once daily. However, a review of the clinical record, including the (MONTH) 2019 TAR, revealed no evidence of that the physician ordered treatment was carried out until 9/19/19. A review of the clinical record and wound physician notes, revealed that R#10 had a history of [REDACTED]. A pressure ulcer was again identified on the left heel on 8/28/19. The 8/28/19 wound physician's Wound Evaluation and Management Summary note documented the pressure ulcer as a 1 x 2 x 0.1 cm Stage 3 with 100% granulation tissue. The wound physician ordered a treatment of [REDACTED]. However, a review of the clinical record revealed no evidence that the physician ordered treatment was being carried out. A review of the (MONTH) through (MONTH) 2019 TAR's revealed evidence of physician ordered treatmentes being provided to additional existing pressure ulcers on the left lower extremity, inlcluding the left foot and left lateral foot, but not the left heel. The most recent wound physician report from 10/2/19 documented no change in the wound progress from the previous week's assessment. During an interview on 10/9/19 at 8:40 a.m., the wound physician stated that when he gives the nurses orders, he expects those orders to be entered (into the clinical record) and followed. He confirmed that the left medial foot pressure ulcer had worsened and combined with another existing left foot pressure ulcer. He stated that he was unsure why the left foot wounds were worsening, that it could be due to age, nutrition, blood supply or treatements not being done. He stated that the resident was not eating and felt that he would have been appropriate for hospice services but the family did not want hospice services. He stated that he suspects nursing staff were providing treatments. Further interview with the Wound Physician regarding the white insects revealed that the Wound Physician stated that they can have a positive impact because they eat dead tissue but when they are used medically they are sterile versus something flying into the dressing but the Wound Physician stated he was not personally concerned about it. During an interview with R#10's primay physician, he stated that he expected the nurses to carry out the orders given by the wound physician. The physician stated that given the resident's advanced age, terrible [MEDICAL CONDITION] and poor nutrition along with his immobility and it was understandable that the resident developed the pressure ulcers. He added that nursing staff couldn't change his position in bed enough to prevent them. 2. R#9 had [DIAGNOSES REDACTED]. A care plan was in place that included that the resident had potential and actual impairment (of skin) to the right upper back on 8/20/19 and to the right ishium on 9/25/19. The care plan included an intervention for nursing staff to provide weekly rounds with the wound team with measurements. However, there was no evidence in the clinical record that the pressure ulcer to the right ishium was assessed with [REDACTED]. A review of the Skin Integrity Reports for R#9 revealed that a pressure ulcer was identified to the right ishium on 9/24/19. The pressure ulcer is documented on the report as measuring 2.8 x 2 x 0.1 cm with a 100% necrotic wound bed. During an interview on 9/30/19 at 3:20 p.m., LPN tx nurse FF, clarified that the necrotic tissue was not black eschar, but was green. She stated that the wound physician would be evaluating it on the following Wednesday, 9/30/19. However, there was no evidence in the clinical record that the wound physician or facility nursing staff assessed the pressure ulcer to the right ishium after 9/24/19, until 10/9/19. During an interview on 10/9/19 at 8:40 a.m., the wound physician stated he was not made aware of the pressure ulcer to the right ishium until 10/9/19 and assessed it and debrided the necrotic tissue. R#9 also had a pressure ulcer to the right upper back. A review of the clinical record, facility Skin Intergrity Reports, and the wound physician's notes revealed conflicting documentation concerning the description of the pressure ulcer and treatments obtained prior to the wound physician assessing it on 8/28/19. The pressure ulcer was first assessed on the Skin Integrity Report by LPN Treatment Nurse FF on 8/21/19 as being unstageble but with a 100% granulation wound bed and measuring 2.5 x 1.4 cm x unmeasurable depth. However a Skin/Wound note from the day before, on 8/20/19 documents a late entry and includes that the resident is being followed by the wound team for necrosis of the right upper back with measurements of 1.5 x 1.3 x 0.2 cm. A further review of the clinical record revealed that prior to the 8/20 and 8/21/19 wound assessments, a open area to the right upper back was noted on a weekly skin assessment completed on 8/16/19 but with no further description or documented action taken. In addition, an 8/17/19 Change in Condition Evaluation form was completed that documented a skin wound or ulcer to the right side of the mid back that started on 8/16/19. The form also notes that the clinician was notified and recommended a dressing be applied and wound care nurse notified. However, there is no evidence in the clinical record ,including on the (MONTH) 2019 TAR, of what treatment order was obtained and carried out until after 8/28/19. On 8/28/19 the wound physician assessed R#9's pressure ulcer to the right upper back as unstageable with thick adherent devitalized necrotic tissue, and measuring 1.5 x 1.3 x 0.2 cm. The wound physician ordered a treatment of [REDACTED]. A review of the (MONTH) TAR revealed that the treatment order was added on 8/29/19 and documented as being provided. During an observation on 10/1/19 at 8:25 a.m. with LPN Treatment Nurse FF, the resident was observed to have a pressure ulcer to the right ishium and right upper back. The pressure ulcer to the right ishium was noted to be open, with yellow slough covering the wound bed. The pressure ulcer to the right mid back was observed to be open with a mixture of granulation tissue and slough to the wound bed. During the interview with the wound physician on 10/9/19 at 8:40 a.m., he stated that R#9 wanted to sit up for long periods of time without lying down. He stated that he had talked to her about this but that she still wanted to sit up (in the wheelchair). 3. R#2 had [DIAGNOSES REDACTED]. A care plan was in place that included that the resident was at risk for skin breakdown due to impaired mobility and cognition and incontinence with an intervention for licensed nursing staff to provide treatments as ordered. R#2 had been receiving hospice services since 3/29/19. On 7/19/19, the hospice nurse assessed the resident and documented three pressure ulcers and obtained treatment orders. The resident was assessed as having a 2.4 x 1.3 cm unstageable pressure ulcer with slough to the mid-coccyx, a 1.1 x 0.6 stage 2 to the right uppr buttock, and a 0.5 x 0.4 cm stage 2 to the coccyx. The physician's orders [REDACTED]. However, a review of the clincial record and hospice records revealed that the physician ordered treatments were not provided consistently. A review of the (MONTH) 2019 TAR revealed that the treatment orders for the three separate pressure ulcers were not listed on the TAR as three separate orders ,but as two treatment orders, one for the right buttock and one for the sacrum. A further review of the clinical record and hospice documentation revealed no evidence that treatments were provided every two days as ordered between 7/19/19 and 7/24/19 and between 7/24/19 and 7/30/19. On 7/30/19 the hospice nurse documented on the Visit Note Report that the dressing to the wound on the buttocks was dated 7/24/19. R#2's pressure ulcers resolved by 9/4/19. During an observation on 9/24/19 at 3:20 p.m. with LPN Treatment Nurse FF, the skin was observed to be intact to the buttocks and coccyx. 4. Resident #12 (R#12) admitted to the facility on [DATE] with a pressure ulcer wound to his sacrum. He entered the facility with [DIAGNOSES REDACTED]. R#12 is severely cognitively impaired and totally dependent on the staff for his care and treatments. Review of the Treatment Administration Records (TARs) for his unstageable deep tissue injury (DTI) to his sacrum wound revealed the following missing documentation of treatment days: June 2019 6/8/19, 6/15/19, 6/16/19, 6/23/19 and 6/29/19 July 2019 7/5/19, 7/6/19, 7/7/19, 7/11/19, 7/12/19, 7/14/19, 7/15/19, 7/16/19, 7/17/91, 7/19/19, 7/20/19, 7/23/19, 7/24/19, 7/25/19, 7/26/19, 7/27/19, 7/29/19, 7/30,/19 and 7/31/19 August 2019 8/1/19, 8/2/19, 8/3/19, 8/4/19, 8/5/19, 8/8/19, 8/9/19, 8/14/19, 8/15/19, 8/16/19, 8/17/19, 8/18/19, 8/19/19, 8/20/19, 8/21/19, 8/22/19, and 8/23/19 September 2019 9/13/19, 9/14/19, 9/15/19, 9/22/19, 9/27/19 and 9/28/19 October 2019 10/2/19 and 10/3/19 Review of the TARs for his unstageable deep tissue injuries to his bilateral elbow wounds revealed the following missing documentation of treatment days: June 2019 6/29/19 and 6/30/19 July 2019 7/5/19, 7/11/19, 7/14/19, 7/20/19, 7/23/19 7/28/19 and 7/29/19 August 2019 8/16/19, 8/18/19 and 8/22/19 September 2019 9/27/19 October 2019 10/3/19 Review of the nursing progress notes reveals inconsistencies of dressing changes/treatments. Nursing Progress Note dated 9/20/19 at 14:51, Late Entry: Note Text: No wound care done, dressings were soiled and dated from the 16th. This note does not indicate if this was the sacrum or elbow wounds. Nursing Progress Note dated 9/21/19 at 8:22 a.m., Late Entry: Note Text: wounds are still dressed with the bandage from the 18th and are all soiled and have not been changed. No wound care done. This note does not indicate if this was the sacrum or elbow wounds. Nursing Progress Note dated 9/25/19 at 14:53, Late Entry: Note Text: no wound care done, dressings were dated from 9/23/19 and soiled. This note does not indicate if this was the sacrum or elbow wounds. During an interview with the wound care physician on 10/9/19 at 8:20 a.m., he stated that sees R#12 weekly. He also stated that this is the first time he was made aware that the documentation for R#12's wounds was incomplete on the part of the facility. He stated that this resident has multiple co-morbidities and is very medically compromised. He then stated that R#12's wounds were slowly healing and he believed they would get better but very slowly. He stated that the facility had been through several wound care nurses and things have fallen off the plate. He suspected that wound care was done more often than it was documented because he sees this resident's wounds getting better. During an interview with LPN Hall Nurse, GG, on 10/9/19 at 12:31 p.m., she stated she was tired of finding dressings that were soiled and that had not been changed. She stated that at one time she found supplies in a resident room like the dressing change was set up to be done and then it was left undone. She stated she just started helping out with the facility wounds when her job was done on the hall passing medications etc. She stated she would feel like she is abandoning these residents if she didn't help all that she could. 5. Resident #13 (R#13) was admitted to the facility on [DATE] with a right heel and right leg pressure ulcer wound. Other [DIAGNOSES REDACTED]. Resident #13 is able to make her needs and desires known to staff and others and is moderately dependent on staff for her activities of daily living (ADL). Review of the Treatment Administration Records (TARs) for her right leg wound revealed the following missing documentation of treatment days: September 2019 9/13/19, 9/14/19, 9/15/19, 9/16/19. 9/22/19, 9/28/19, and 9/29/19 October 2019 10/2/19, 10/4/19 and 10/5/19 Review of the TARs for her right heel wound revealed the following missing documentation of treatment days: September 2019 9/13/19, 9/14/19, 9/15/19, 9/16/19, 9/22/19, 9/27/19, 9/28/19 and 9/29/19 October 2019 10/2/19, 10/4/19 and 10/5/19 During an interview with R#13 on 10/7/19 at 1:05 p.m., she stated she was waiting to have her wounds dressed. She stated they usually do her dressing changes but sometimes she has to remind them to do it. During an interview with one of the hall nurses, LPN, GG, on 10/9/19 at 12:31 p.m, she stated that not having the wound dressings completed has been a problem for along time. She stated that she manages one of the halls in the building but helps with the wounds when she is able. She also stated that either they were done at night by the Director of Nursing, when she would return to the building or they just didn't get done. | 2020-09-01 |