cms_WV: 9595
Data source: Big Local News · About: big-local-datasette
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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9595 | COLUMBIA ST. FRANCIS HOSPITAL | 515110 | 333 LAIDLEY STREET | CHARLESTON | WV | 25322 | 2011-02-16 | 314 | G | 0 | 1 | Q8EN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and staff interview, the facility failed, for one (1) of eighteen (18) Stage II sample residents, to provide care and services to prevent the development of pressure ulcers for a resident who entered the facility without pressure ulcers and/or to promptly identify and treat pressure sores after they developed, in order to promote healing. Resident #100, who was assessed as having no skin impairment upon admission to the nursing unit on 02/02/11, was identified by the occupational therapist as having skin breakdown on the buttocks and lower extremities on 02/03/11. However, there was no evidence of nursing documentation acknowledging the presence of any skin breakdown until 02/06/11, when Wound #1 (a Stage II pressure sore) was identified and first treated. Wound #2 (also a Stage II pressure ulcer) was identified and first treated on 02/07/11. When the resident's skin was observed in the presence of a facility nurse on 02/10/11, Wound #1 was dressed, Wound #2 had no dressing on it, and a third wound (also a Stage II) was found which had not previously been identified or treated by facility staff. Resident identifier: #100. Facility census: 19. Findings include: a) Resident #100 Record review revealed Resident #100 was admitted to the facility on [DATE]. Upon admission to the facility, a registered nurse (RN - Employee #12) completed an admission report which stated Resident #100 had no skin problems, recording no impairment on the skin risk assessment. On 02/03/11, the occupational therapist gave Resident #100 a bath. The occupational therapist subsequently documented the following: SKIN: Some breakdown on buttocks and LE's (abbreviation for lower extremities). Nursing is treating. Prior to 02/06/11, no documentation could be found to support that nursing was treating the pressure areas. No evidence was found for further assessment of Resident #100's skin integrity until 02/06/11, when an employee documented the following: Location of Wound #1 Right / Left Buttocks Type: Blister / Excoriation Stage: II - Break In Skin - Blister Margins: Pink Wound Bed: Pink Drainage: None Allevyn adhesive dressing was applied. A Stage II pressure area is described by the National Pressure Ulcer Advisory Panel (www.npuap.org ) as a partial thickness of dermis presenting as a shallow open ulcer with a pink wound bed, without slough. May also present as an intact or open / ruptured serum filled blister. Record review found no evidence that nursing was treating any pressure ulcers prior to 02/06/11. On 02/07/11, another RN (Employee #21) documented the following: Wound Location: RT (right) BUTTOCK Type: PRESSURE ULCER Stage: II - BREAK IN SKIN - BLISTER Margins: RED Wound Bed: RED Drainage: Y Description / Odor: SANGUINOUS Employee #21 measured Wound #1 to be 1 cm x 0.7 cm x 0.1 cm. Wound #2 was measured to be 2.0 cm x 0.5 cm x 01. cm and was identified as a Stage II pressure ulcer. Allevyn dressing was applied to Wound #1, and Sensicare was applied to Wound #2. On 02/10/11 at 9:35 a.m., after reviewing the occupational therapy notes dated 02/03/11, the clinical coordinator (Employee #34) was asked why there was no nursing documentation related to the findings. She stated she was not sure Resident #100 had any pressure ulcers. She said, It may just be excoriation. I need to go look. Employee #34 and this nurse surveyor went to look at Resident #100. Upon observation, Resident #100 had three (3) Stage II pressure ulcers to the buttocks and coccyx, one (1) which had not previously been identified. He had only one (1) Allevyn dressing to one (1) of the pressure ulcers. The second pressure ulcer (identified on 02/07/11) did not have a dressing on it. According to Employee #34, if a Stage II pressure ulcer is identified, the treatment would require a dressing. On 02/10/11 at 11:15 a.m., Employee #34 reported she asked the occupational therapist why she wrote, Nursing is treating. According to Employee #34, the occupational therapist replied, I just assumed that nursing was treating. | 2015-10-01 |