cms_AK: 64
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 64 | WRANGELL MEDICAL CENTER LTC | 25015 | P.O. BOX 1081 | WRANGELL | AK | 99929 | 2018-04-30 | 686 | D | 0 | 1 | O8F911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure 1 resident (#10), out of 8 sampled residents, received the necessary care and services to prevent the development of a pressure ulcer. Failure to identify potential risk for development of, or provide appropriate interventions on a timely basis upon admission, to prevent pressure ulcers, placed resident at an increased risk for developing an avoidable pressure ulcer. Findings: Record review on 4/23-27/18, revealed Resident #10 was admitted to facility on 10/2/17 with [DIAGNOSES REDACTED]. Review of admission MDS (Minimum Data Set), dated 10/11/2017, revealed Resident #10 was coded as requiring extensive assistance during bed mobility and locomotion on/off unit. The Resident was coded as being totally dependent during transfers and toileting. Review of Resident #10's Admission Nursing Assessment, dated 10/2/17, revealed no skin assessment completed upon admission. Further review of nursing notes for the month of (MONTH) (YEAR) revealed the first documented skin assessment was completed 10/11/17 which stated .(had) a bath today, and skin was intact. Review of Resident #10 nursing note dated 10/18/1,7 revealed During shift change report I was informed that (Resident #10) has a healed decubitus ulcer to coccyx (tailbone area); during .weekly skin assessment I noted that the ulcer is still there, but healing. Review of Resident #10's Wound Assessment Report dated 10/19/17, revealed a Stage 2 (Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist) pressure ulcer was present on the coccyx. The assessment further revealed the wound was described as: Length 0.20cm, Width 0.20cm, Depth 0.10cm. Picture taken on 10/19/17, by the wound care nurse, revealed an open red area to the coccyx. Review of Resident #10s admission orders [REDACTED]. Review of Resident #10's medical record nursing note dated 10/19/17, revealed has a new bed to assist with coccyx soreness. Review of Resident #10's Wound Assessment Report dated 10/25/17, revealed pressure ulcer remained at a Stage 2 with unchanged dimensions. Review of the wound picture taken on 10/25/17, by the wound care nurse (WCN), revealed the pressure ulcer area had become an open area, exposing the moist pink/red tissue bed. Review of Resident #10's medical record revealed a physician's orders [REDACTED]. Cleanse with (normal saline), Foam dressing BIW (twice weekly) & PRN (as needed), Report if not better 4 weeks. Review of Resident #10's treatment report revealed weekly skin assessments were marked as intact from 10/14/17 to 12/30/17, despite having a wound assessment done on 10/19/17 and 10/25/18. In addition, the treatment report indicated dressing changes to pressure ulcer from 10/31/17 to 11/24/17. During an interview on 4/26/18 at 2:15 pm, with Licensed Nurse (LN) #2 confirmed no skin assessment was completed upon Resident #10's admission. During an interview on 4/26/18 at 2:30 pm, WCN confirmed documentation showed no assessment completed upon admission. The WCN stated Resident #10's pressure ulcer was acquired/re-opened post-admission to the facility. | 2020-09-01 |