cms_AK: 82
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 |
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
82 | PROVIDENCE TRANSITIONAL CARE CENTER | 25018 | 910 COMPASSION CIRCLE | ANCHORAGE | AK | 99504 | 2018-03-15 | 686 | D | 1 | 0 | M2PE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > . Based on record review, observation, and interviews the facility failed to ensure measures to prevent a pressure injury for 1 resident ( #1) out of 2 residents reviewed with pressure injuries, were implemented. This failed practice placed the resident at risk for worsening pressure injuries. findings: Record review on 3/14-15/18 revealed Resident #1 was admitted to the facility for comfort care (care for someone with a terminal illness) and had [DIAGNOSES REDACTED]. The Resident was admitted with a pressure injury to the right hip, a deep tissue injury to the right metatarsal head (on the foot), and a reddened area to the left heel. Review of the Wound/Skin Care Orders/ TAR (Treatment Administration Record), (MONTH) (YEAR), revealed Wound Number:3 Dx. Wound [MEDICATION NAME] (prevention) Location: L (left) Heel. the treatment was a Foam Dressing Allevyan heel. Review of the Resident's Care Plan, dated 12/14/17, revealed I have a skin injury .sometimes get confused or can't remember things, can't move around well on my own . The Approach included I need my aides to-help me reposition at least every 1-2 hours while I'm in bed .elevate my heels in bed. Observation on 3/14/18 at 12:24 pm, Resident #3 was observed lying supine on an air mattress. The Resident's heels were resting directly on the mattress. Observation on 3/14/18 at 12:50-1:00 pm, Certified Nursing Assistant (CNA) #1 and Licensed Nurse #1 repositioned Resident #1 in the bed. Both Resident's feet were lying directly on the bed and the heels were not elevated on a pillow to be off the bed. The Resident began to cry out that his/her left leg hurt. During an interview on 3/14/18 at 1:03 pm, when asked about Resident #1's heels, CNA #2 stated the Resident had sores on both his/her heels. When asked if there were any skin precautions for the heels, the CNA replied Resident #1 had a pink dressing to his/her left heel to protect it and the staff place a pillow between the Resident's legs to prevent them from rubbing together. During an observation on 3/15/18 at 9:00 am, Resident #1 was observed lying on his/her right side in the bed, the Resident's left heel was covered with the pink foam dressing. Both of the Resident's heels were both resting directly on the bed. During an interview on 3/15/18 at 1:00 pm, when asked about Resident #1's pressure injuries, and how facility staff were to keep pressure off the Resident's right heel, the Wound Nurse stated it was on the care plan. Review of Resident #1's Baseline Care Plan/RDCP (Resident Daily Care Plan), undated, revealed Special Precautions: float heels on heel elevation cushion while in bed. | 2020-09-01 |