| 38 |
DESERT TERRACE HEALTHCARE CENTER |
35014 |
2509 NORTH 24TH STREET |
PHOENIX |
AZ |
85008 |
2017-12-05 |
686 |
D |
0 |
1 |
6GPJ11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, resident and staff interviews, review of the National Pressure Ulcer Advisory Panel's (NPUAP) Pressure Injury Stages guidelines and policy review, the facility failed to ensure a pressure ulcer was accurately staged, thoroughly assessed and consistently monitored for one resident (#147). Findings include: Resident #147 was admitted on (MONTH) 20, (YEAR), with [DIAGNOSES REDACTED]. The Initial Admission Record dated (MONTH) 20, (YEAR) included the resident was alert and oriented to time, place and person. Skin integrity findings included the resident had a surgical wound to left outer ankle. There was no documentation that the resident had any pressure ulcers upon admission. However, a nutrition care plan dated (MONTH) 20, (YEAR) included the resident required increased calories and protein needs related to wound healing, due to a pressure injury. The stage and location of the pressure injury was not identified. Review of the Weekly Skin Evaluation dated (MONTH) 21, (YEAR) revealed the resident had a stage II pressure ulcer to the left inner lower leg, which measured 3.5 centimeters (cm) x 1.0 cm, and the wound bed was described as having yellow slough. However, a stage II pressure ulcer in this document was defined as partial thickness loss of dermis, presenting as shallow open ulcer with a red pink wound bed without slough. A stage III pressure ulcer was defined as full thickness tissue loss and slough may be present. Further review of the evaluation revealed there was no documentation if the wound had any drainage, odor, the condition of the surrounding skin or progress of the wound. The skin integrity care plan dated (MONTH) 21, (YEAR) included the resident had actual skin impairment. However, the care plan did not include the identification of the pressure ulcer to the left inner lower leg. Interventions included following facility protocol for treatment of [REDACTED]. A physician's orders [REDACTED]. A physician's note dated (MONTH) 23, (YEAR) included the resident was alert and oriented to person and purpose and that the left lower extremities could not be accurately assessed, due to orthopedic splinting. The note did not include that the resident had a pressure ulcer to the left leg. Per the Weekly Skin Evaluation dated (MONTH) 23, (YEAR), the pressure ulcer continued to be documented as a stage II to the inner leg, with slough. No measurements or description of the pressure ulcer was included. A review of the Dietary Admission Evaluation dated (MONTH) 27, (YEAR) revealed the resident had a stage II pressure ulcer to the left leg. The admission MDS (Minimum Data Set) assessment dated (MONTH) 27, (YEAR) included the resident had one stage II pressure ulcer, with slough which was present on admission. However, a stage II pressure ulcer as defined in the MDS includes partial thickness loss of dermis, presenting as shallow open ulcer with a red pink wound bed, without slough. Per the Wound Administration Record for (MONTH) (YEAR), the treatments were provided as ordered. In the Weekly Skin Ulcer Note dated (MONTH) 5, (YEAR), the pressure ulcer to the left inner leg was not included in the documentation. Despite documentation that the resident had a pressure ulcer with slough to the left inner leg, there was no documentation that it had been thoroughly and accurately assessed from admission through (MONTH) 5, (YEAR). An interview with a wound nurse (staff #48) was conducted on (MONTH) 5, (YEAR) at 8:56 a.m. She stated that she conducts a head to toe assessment of the resident the day after admission and is responsible to ensure accurate identification, including staging, a description of the wound bed, surrounding skin and measurements. She stated that the floor nurses are not allowed to identify the specific type of wound and cannot stage a pressure ulcer. She said that pressure ulcers are assessed twice daily. Further, she stated that each wound is documented separately and pressure ulcers are documented on the Weekly Pressure Ulcer note. Staff #48 stated that the documentation should include the stage, measurements a description of the wound bed and surrounding area. She also stated that the status of the wound whether it is improving or not should be in the wound notes. Staff #48 stated that resident #147 has one stage II pressure ulcer to the back of the left ankle, which was first identified on (MONTH) 21. In an interview with a licensed practical nurse (LPN/staff #73) conducted on (MONTH) 5, (YEAR) at 11:27 a.m., she stated that when a wound is observed on a resident, she will notify the wound nurse who will accurately identify, stage and provide daily treatments to the wounds. She stated that she cannot identify the type of wound but would describe what she sees in her notes. During an interview with the Assistant Director of Nursing (ADON/staff #61) conducted on (MONTH) 5, (YEAR) at 1:15 p.m., she stated that if the resident has any type of wound, the floor nurses will only describe what they see. She stated that the wound nurse ensures weekly measurements of wounds and documentation includes measurements, description of the wound bed, any drainage and surrounding skin. In an interview with the Director of Nursing (DON/staff #66) conducted on (MONTH) 5, (YEAR) at 3 p.m., she stated the resident has one stage II pressure ulcer to the left inner lower leg, which was identified upon admission. She stated that the wound nurses have not been documenting the assessment of the resident's pressure ulcer and she has educated them to document the assessments on the pressure ulcer sheet. During another interview with staff #66 conducted on (MONTH) 5, (YEAR) at 3:20 p.m., she stated that there were no complete assessments of the resident's pressure ulcer, prior to (MONTH) 5, (YEAR). Review of the NPUAP Pressure Injury Staging guidelines revealed that a stage II pressure injury was described as having partial-thickness skin loss with exposed dermis, with a viable, pink or red, moist wound bed and slough and eschar are not present. Further, a stage III pressure injury was defined as a full-thickness skin loss and slough and/or eschar may be visible. Regarding the CAM boot: The Physical Therapy (PT) Evaluation and Plan of Treatment dated (MONTH) 21, (YEAR) included the resident was status [REDACTED]. The section on Medical Precaution/Contraindications included for a left CAM (Controlled Ankle Motion) boot. However, there was no documentation as to when this boot should be applied or removed, or the duration (days, weeks etc) the boot was to be utilized. Review of the resident's care plans dated (MONTH) 21, (YEAR) revealed the use of a cam boot to the left lower leg was not included as an intervention. A nurse practitioner (NP) progress note dated (MONTH) 22, (YEAR) included an alert and oriented resident with an assessment of polytrauma and difficulty of walking. Musculoskeletal findings included the left lower extremity had a dressing and a stabilization splint. The plan included for physical and occupational therapy, and to monitor the resident's progress. There was no documentation regarding the use of the CAM boot as part of the plan of care. A physician's note dated (MONTH) 23, (YEAR) included the left lower extremity could not be accurately assessed, due to orthopedic splinting. Review of the physician's orders [REDACTED]. Review of the clinical record including the Treatment Administration Record from (MONTH) 20, through (MONTH) 31, (YEAR) revealed no evidence that use of the boot to the left lower leg was monitored and documented. An observation was conducted on (MONTH) 4, (YEAR) at approximately 12:55 p.m. of the resident in bed, with a black boot on the left lower leg, which was laying on top of a pillow. At this time, the resident stated that the boot was for her left leg, because of her accident. Another observation was conducted on (MONTH) 5, (YEAR) at 8:51 a.m., of the resident sitting in her wheelchair. The black boot was observed to be on her left leg. An interview was conducted with a certified nursing assistant (CNA/staff #9) on (MONTH) 5, (YEAR) at 10:54 a.m. She stated the resident wears a boot on her left leg for strengthening. She stated that the resident puts it on and takes it off by herself. She also stated that the resident is supposed to remove the boot when in bed and put it back on when out of bed. Staff #9 stated she tries to ensure that the resident does this and will inform the nurse if it's not done, because there is no way for her to document it. During an interview with a certified occupational therapist (COTA/staff #118) conducted on (MONTH) 5, (YEAR) at 11:08 a.m., he stated that the resident has weight bearing limitations on her left side. He stated the boot to the left leg was for protection of the leg status [REDACTED]. An interview with a physical therapist (PT/staff #119) was conducted immediately following. Staff #119 stated that the order for the use of [REDACTED]. He stated that if the order did not specify a frequency, then the boot is to be worn at all times. An interview with an LPN (staff #73) was conducted on (MONTH) 5, (YEAR) at 11:27 a.m. She stated that the resident has a black boot on her left leg. At this time, a review of the clinical record was conducted and staff #73 stated that she could not find an order for [REDACTED].>An interview with the wound nurse (staff #48) was conducted on (MONTH) 5, (YEAR) at 11:25 a.m. She stated that there usually is an order for [REDACTED]. A review of the clinical record was conducted with the Assistant Director of Nursing (ADON/staff #61) on (MONTH) 5, (YEAR) at 1:15 p.m. She stated that she could not find an order for [REDACTED].>In a later interview with staff #61 on (MONTH) 5, (YEAR) at 1:52 p.m., she stated that she reviewed the records and found no orders for the CAM boot. Staff #61 stated if a resident uses a CAM boot, the floor nurse is expected to ensure that there is an order for [REDACTED]. During an interview with the Director of Nursing (DON/staff #66) conducted on (MONTH) 5, (YEAR) at 2:06 p.m., she stated there was no order for the use of [REDACTED]. She stated that if the resident came with a boot and there was no order for its use, the nurses are expected to communicate, document and call the physician to verify the continued use of the boot. She also said that per the therapy department, the resident still needed the boot, so the physician has been notified. Review of the policy regarding Physician order [REDACTED]. of care. The policy on Wound Management included that it the facility's policy to have a central consistent flow sheet to enable medical staff to evaluate the status of wounds. The policy also included that weekly skin assessments on all residents will be done and documented in the nurses notes. Per the policy, each wound will be measured in centimeters weekly and include drainage, odor, color and a short statement on progress (or lack of) and this will be documented on the wound flow sheet. |
2020-09-01 |