cms_WV: 9600
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 9600 | HILLCREST HEALTH CARE CENTER | 515117 | P.O. BOX 605 | DANVILLE | WV | 25053 | 2012-10-05 | 314 | G | 1 | 0 | D8F011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and review of the facility's policy and procedure for, Introduction to Prevention and Management of Wounds, the facility failed to; accurately and timely assess the pressure areas, administer treatments as ordered by the physician to promote wound healing, evaluate the effectiveness of the treatments in place, and follow their policy for treatment of [REDACTED]. This was true for two (2) of three (3) residents reviewed for pressure ulcers. Resident identifiers: #81 and #18. Facility census: 89. Findings include: a) Resident #81 Resident #81 was admitted to the facility on [DATE] at 7:34 p.m. According to the nursing admission note, he was admitted with a stage II pressure ulcer to the coccyx. Upon admission, an order was present to clean the Stage II pressure area to the coccyx with normal saline solution, pat dry and apply Combiderm every day. Review of the treatment administration record (TAR) for July found the treatment was not provided as ordered from 07/13/12 through 07/24/12, when the resident was discharged from the facility and admitted to the hospital. On 07/27/12 the resident was readmitted to the facility at 3:50 p.m. admission orders [REDACTED]. On 07/27/12 a physician's order was present to, cleanse The Stage II pressure ulcer to coccyx with Saf-clens, AF wound cleanser, apply duoderm, change every three (3) days and as needed. Review of the TAR found the first treatment to the pressure area was not provided until 07/30/12. Review of the medical record found no assessment, including a measurement of the pressure area, or evaluation of the pressure ulcer from 07/13/12 until 08/02/12. There was no documentation present to verify the measurements of the pressure area on the 07/13/12 admission or the re-admission on 07/27/12. On 08/02/12 a, pressure ulcer evaluation, form was completed which included measurements, treatment, and a description of the wound. On 08/02/12 the Stage II pressure ulcer had increased to a Stage III pressure ulcer according to the information contained in the evaluation. The pressure ulcer evaluation form, with a facility effective date of 07/01/12, was not completed until 08/02/12. Review of the facility policy and procedure for introduction to prevention & management of wounds, found, . If the patient / resident is admitted with an open wound or develops a wound after admission, the plan will then expand to include the use of an appropriate debridement and dressing regimen and the consideration for the use of modalities for wound healing . weekly staging of pressure ulcers. The director of nursing (DON), Employee #88 and the regional director, Employee #89 were interviewed at 2:15 p.m. on 10/02/12. These employees were unable to provide any further information to verify the resident's pressure ulcers was treated according to physician's orders and the pressure area was assessed and monitored on a weekly basis from 07/13/12 thorough 08/02/12. b) Resident #18 The resident was admitted to the facility on [DATE]. The admitting nursing note included, . Open area to coccyx measures 1.5 cm. (centimeters) by 1.5 cm. Wound bed white in color with no drainage noted. Open area to right buttock measures 1.5 cm. by .5 cm. Wound bed pink with no drainage noted. admission orders [REDACTED] 1. Cleanse open area to coccyx with normal saline solution, pat dry, apply [MEDICATION NAME] and cover with border gauze, change every three (3) days and as needed. 2. Cleanse open area to right buttocks with normal saline solution, pat dry. Apply [MEDICATION NAME], cover with border gauze, change three (3) days and as needed. Review of the TAR found the above orders were never transcribed to the TAR and the treatment was not provided. On 09/12/12 new orders were written for : 1. discontinue previous treatment order to coccyx and right buttock. 2. Cleanse stage III to coccyx and stage II to right buttocks with saf-cleanse, pat dry, apply saf-gel to stage III slough area and cover both stage III and stage II with combiderm every 3rd day and as needed. Further review of the TAR found these ordered were not implemented until 09/15/12. Therefore, the resident did not receive any treatment for [REDACTED]. Upon admission a non-pressure skin condition form was completed for the area on the coccyx which measured 1.5 cm. in length and 1.5 cm in width, depth 0.0. On 09/14/12 a pressure ulcer evaluation form was completed and detailed the measurements of the Stage III pressure area to the coccyx. On 09/14/12, the wound to the coccyx measured 1.7 cm. in length and 1.8 cm in width, depth was 0 cm. The pressure area to the coccyx increased in size from 09/10/12 to 09/14/12. The DON, Employee #88 and the regional corporate nurse, Employee #89, were interviewed on 10/02/12 at 2:15. No further information was provided to verify the resident's pressure ulcers were treated according to physician's orders. There was no evidence the resident received treatment to the pressure area for five (5) days after admission and no evidence to support the resident's pressure ulcers had not increased in size during the time the treatments were not provided. | 2015-10-01 |