| 85 |
HATLEY HEALTH CARE INC |
15023 |
300 MEDICAL CENTER DRIVE |
CLANTON |
AL |
35045 |
2018-05-10 |
686 |
D |
0 |
1 |
YKK111 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview and record review, the facility failed to ensure: (1) Resident Identifier (RI) #53, a resident at risk for developing pressure ulcers, intervention to have his/her feet elevated off the mattress, and to wear heel protectors while in bed was implemented. This was observed on two of three days of the survey; and (2) RI #15 and RI #93, residents at risk of developing pressure ulcers, had cushion on the oxygen tubing behind their ears. This was observed on two of three days of the survey. These deficient practices affected RI #53, one of three residents sampled for pressure ulcers, and RI #15 and RI #93, two of three sampled residents using oxygen: Findings Include: (1) RI #53 was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. RI #53's Pressure Ulcer care plan, with a Problem Onset date of 06/14/17, documented: . Approaches . * Apply heel protects to feet while in bed and float heels . A Quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 02/21/18, identified RI #53 as being at risk for pressures ulcers. On 05/09/18 at 10:32 a.m., the surveyor observed the Treatment Nurse, Employee Identifier (EI) #11, prepare to provide wound care to the top of a toe on RI #53's right foot. RI #53's feet were on the mattress and no heel protectors were worn at this time. On 05/10/18 at 8:01 a.m., the surveyor observed RI #53's bare feet on the mattress, with no heel protectors on. On 05/10/18 at 2:30 p.m., the surveyor conducted an interview with EI #12, RI #53's assigned Certified Nursing Assistant (CNA). The surveyor asked EI #12 how should RI #53's feet be when he/she was in bed. EI #12 said they should be elevated on pillows so RI #53's heels would not rub on the bed and get a pressure sore on them. The surveyor asked EI #12, according to RI #53's plan of care, what should be on RI #53's feet. EI #12 said heel protectors. When asked what was the rationale for RI #53 having on heel protectors, EI #12 replied, so RI #53's feet would be off the bed and it would release pressure from his/her heels. EI #12 and the surveyor went to RI #53's room to see if there were heel protectors in the room. EI #12 looked in RI #53's dresser drawers and stated there were no heel proctors in RI #53's room. (2) RI #15 was admitted to the facility on [DATE], and readmitted on [DATE], with a [DIAGNOSES REDACTED]. A Significant Change MDS assessment, with an ARD of 01/19/18, identified RI #15 as being at risk for pressures ulcers. RI #15's Oxygen Therapy care plan, with a Problem Onset date of 02/09/18, documented: . Approaches * Check cushion behind my ears q (every) shift and PRN (as needed) to assure in place appropriately . RI #15's (MONTH) (YEAR) Physician order [REDACTED].> . OXYGEN @ (at) 3LPM (liters per minute) VIA (by way of) NC (nasal cannula) DAILY PRN SHORTNESS OF BREATH . On 05/09/18 at 8:35 a.m., the surveyor observed RI #15's oxygen infusing at 3 liters per minute. There was no cushion on the tubing behind RI #15's ears. On 05/10/18 at 8:48 a.m, the surveyor again observed RI #15 wearing oxygen. There remained no cushion on the tubing behind RI #15's ears. On 05/10/18 at 2:53 p.m., the surveyor conducted an interview with EI #13, the nurse assigned to care for RI #15. The surveyor asked EI #13, according to the care plans of residents who are receiving oxygen, what should they have on the tubing behind their ears. EI #13 said cushion. The surveyor asked EI #13 if there was no cushion on the tubing behind the ears, were the care plans being followed. EI #13 said no. The surveyor asked EI #13 to look behind RI #15's ears and asked did RI #15 have cushion on the tubing behind his/her ears. EI #13 said no. RI #93 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. RI #93's Oxygen Therapy care plan, with a Problem Onset date of 04/13/17, documented: . Approaches * Check cushion behind ears q shift and prn to assure in place appropriately . An Annual MDS assessment, with an ARD of 03/13/18, identified RI #93 as being at risk for pressures ulcers. RI #93's (MONTH) (YEAR) Physician order [REDACTED].> . OXYGEN AT 2 LITERS VIA NASAL CANNULA . On 05/08/18 at 5:29 p.m., the surveyor observed RI #93's oxygen infusing at 2 liters per minute. There was no cushion on the tubing behind RI #93's ears. On 05/10/18 at 7:56 a.m, the surveyor again observed RI #93 wearing oxygen. There remained no cushion on the tubing behind RI #93's ears. On 05/10/18 at 2:53 p.m., the surveyor conducted an interview with EI #13. The surveyor asked EI #13 to look behind RI #93's ears and asked did RI #93 have cushion on the tubing behind his/her ears. EI #13 said no. The surveyor asked EI #13 what was the rational for ensuring cushion was on the tubing behind the residents ears. EI #13 replied, to prevent breakdown. |
2020-09-01 |