| 1746 |
THE WASHINGTON HOME |
95005 |
3720 UPTON STREET NW |
WASHINGTON |
DC |
20016 |
2013-02-21 |
309 |
E |
0 |
1 |
RSE411 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview for seven (7) of 41 sampled residents, it was determined that facility staff failed to ensure that each resident received and the facility provided the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care as evidenced by a failure to: consistently assess and monitor the status of altered skin integrity for two (2) residents; follow through on a physician's order [REDACTED]. [REDACTED]. Residents ' #82, 107, 205, 252, 273, 286 and 292. The findings include: 1. A review of the clinical record for Resident #82 revealed facility staff failed to consistently assess and monitor the status of an alteration in skin integrity and failed to follow through on a physician's order [REDACTED]. A. An electronic entry entitled Incident details dated January 2, 2013 at 10:33 PM read: Resident reported with new open area of inner buttock measure 2.5 cm (centimeter) x 2 cm and cluster of small skin open areas at the same site. (physician named) notified, order given to clean open area with soap and water, pat dry, apply [MEDICATION NAME] each shift after each incontinent care. A nurse ' s entry dated January 3, 2013 at 12:25 AM read, (family member named) called and was informed of skin impairment to sacral area. A review of the corrected quarterly Minimum Data Set (MDS) signed January 8, 2013; assessment reference date January 3, 2013 was coded in Section M, Skin conditions that the resident had one (1) Stage 1 pressure ulcer. The clinical record lacked evidence of monitoring and ongoing assessments of the status of the alteration in skin integrity of the sacral area and/or inner buttocks for Resident #82. There was no evidence of documentation regarding the status of the resident ' s altered skin subsequent to the initial assessment on January 2, 2013. An observation of the resident ' s sacral region on February 19, 2013 lacked evidence of a break in skin integrity. The findings were acknowledged by Employees #4 and #8 during face-to-face interviews conducted on February 20, 2013 at 10AM and 1:00 PM respectively. B. Facility staff failed to follow through on a physician's order [REDACTED]. An interim physician's order [REDACTED]. The clinical record lacked evidence that the resident was evaluated by the wound care team as prescribed. A face-to-face interview was conducted with Employee #4 on February 20, 2013 at 10:00 AM who acknowledged that the record lacked evidence of an assessment by the wound care team. The record was reviewed February 20, 2013. 2. Facility staff failed to identify and implement measures to manage the postural/positioning concerns for Resident #107. Resident #107 was observed on February 20, 2013 at approximately 11:00 AM seated at a table in the common area (day/dining room) in his/her wheelchair. The resident was observed excessively leaning to one side without support to maintain an upright position. There was no evidence of needed torso support. Employee #6 who was present during the time of the observation, was queried regarding the lack postural and/or positioning supports for Resident #107. He/she responded that the resident often falls asleep while seated in his/her wheelchair and tends to lean. He/she asked a staff person to obtain a pillow to assist with positioning. Additional observations of positioning/postural concerns were observed during the survey period as follows: Observed Resident #107 in the activity area on February 14, 2013 at 10:00 AM and 3:00 PM sitting in a wheelchair. The resident was leaning to his/her right without support to maintain an upright position. Observed February 15, 2013 in the activity area at approximately 9:54 AM, Resident #107 was sitting in a wheelchair at a table; the resident was leaning to one side without support to maintain an upright position. A face-to-face interview was conducted with Employee #37 on February 21, 2013 at 11:00 AM. He/she stated that the resident has a [DIAGNOSES REDACTED]. The rehabilitation division had not received a communication from nursing regarding positioning concerns for this resident. He/she stated an evaluation will be conducted. An annual physical therapy (PT) screen dated January 26, 2013 read: patient was seen today for annual screen. There has been no change of condition or any recent change in safety status. Wheelchair in good condition. PT evaluation not indicated. Facility staff failed to identify and implement measures to address the postural/positioning concerns for Resident #107. 3. A review of the clinical record for Resident #205 revealed facility staff failed to consistently assess and monitor the status of an alteration in skin integrity. A nurse ' s entry dated December 31, 2012 read: New (1st recording) for Site - 352. Present on the Coccyx is a skin tear/laceration. The following findings were documented, general comments: This abnormality was recorded using an assessment other than skin & wound during a body check. The clinical record lacked evidence of status of the skin alteration of the coccyx initially identified on December 31, 2012. An observation of the resident ' s skin on February 19, 2013 at approximately 11:30 AM lacked evidence of an alteration of the skin of the coccyx. A face-to-face interview was conducted with Employee #4 on February 19, 2013 at approximately 9:30 AM; he/she acknowledged that the record lacked evidence of the status of the resident ' s alteration in skin integrity identified December 31, 2012. However, he/she stated that the resident ' s skin was intact at present. 4A. Facility staff failed to identify the type of device that was inserted for Resident #252 ' s Intravenous access site. The Central Venous Catheter-Physician order [REDACTED]. There was no evidence that facility staff identified the Device type information (listed above) on the Central Venous Catheter-Physician order [REDACTED].# 252. A face-to-face interview was conducted with Employee #7 on February 21, 2013 at approximately 11:08 AM. He/she acknowledged that the device information was not listed on the Central Venous -Physician order [REDACTED]. The record was reviewed on February 21, 2013. 4B. Facility staff failed to consistently conduct a comprehensive pain assessment for Resident #252 who was in pain and received pain medication. The physician's order [REDACTED]. [MEDICATION NAME] IR 5mg- Take (two) 2 tablets by mouth every (four) 4 hours as needed for severe pain. The November 2012 Medication Administration Record [REDACTED]. The November 2012 Medication Administration Record [REDACTED]. There was no evidence that facility staff consistently conducted an assessment that included a description of the location of the pain; the intensity of the pain (e.g. numeric scale) before to determined whether to administer one or two tablets of [MEDICATION NAME]; and there was no evidence that an assessment was completed after the administration of [MEDICATION NAME] IR 5 mg for mild or severe pain. A face-to-face interview was conducted with Employee #7 on February 21, 2013 at approximately 11:08 AM. He/she acknowledged that the pain assessment was not consistently completed to include the location and the intensity of the pain before the pain medication was administered and after pain medication was administered to determine the effectiveness. The record was reviewed on February 21, 2013. 5. Facility staff failed to consistently conduct a complete pain assessment for Resident #273 who was in pain and received pain medication. The physician's order [REDACTED]. The February 2013 Medication Administration Record [REDACTED]. There was no evidence that facility staff consistently conducted an assessment that included a description of the location of the pain, the intensity of the pain (e.g. numeric scale) before and after the administration of [MEDICATION NAME] IR 5 mg. A face-to-face interview was conducted with Employee #7 on February 20, 2013 at approximately 10:50 AM. He/she acknowledged the aforementioned findings. The record was reviewed on February 20, 2013. 6. Facility staff failed to measure the arm circumference and the external catheter length for Resident #286 ' s Intravenous access site. The Central Venous Catheter -Physician order [REDACTED]. Treatment orders: PICC catheters: Measure upper arm circumference (3 in (inches) or 10 cm (centimeters) above insertion site) on admission, with dressing change and PRN (as needed) . A review of the January 2013 Central line Catheter Treatment Record and Medication Administration Record [REDACTED]. The Central Venous Catheter-Physician order [REDACTED]. Treatment orders: PICC catheters: Measure upper arm circumference (3 in (inches) or 10 cm (centimeters) above insertion site) on admission, with dressing change and PRN (as needed) . Measure external catheter length on admission, with each dressing change and prn . A review of the February 2013 Central line Catheter Treatment Record and Medication Administration Record [REDACTED]. There was no evidence that Resident #286 ' s arm circumference was measured in accordance with the physician's order [REDACTED]. A face-to-face interview was conducted with Employee #7 on February 19, 2013 at approximately 11:45 AM. He/she acknowledged that the arm circumference and the length of the external catheter were not measured. The record was reviewed on February 19, 2013. 7. Facility staff failed to ensure that Resident #292 received Incentive Spirometer treatments as prescribed. Resident #292 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The admission orders [REDACTED]. A review of the February 2013 Treatment Administration Record revealed that the order, Use the Incentive Spirometer every 1-3 hours while awake until normal activity is resumed. was transcribed for frequency as FYI (for your information). There was no evidence in the clinical record that facility staff carried out the order for the resident to use the Incentive Spirometer every one (1) to three (3) hours. A face-to-face interview was conducted on February 20, 2013 at 10:25 AM with Employee #22. He/she stated, We test the resident ' s oxygen levels each day during therapy. On evaluation (he/she) did the incentive spirometer. We discussed it daily. I instructed (him/her) to do it every commercial break. I made sure (he/she) knew how to do it and understood the instructions. A face-to-face interview was conducted on February 20, 2013 at 11:10 AM with Employee #21. He/she stated, You could hear the [MEDICATION NAME] when (he/she) was using it. I was in the room with (him/her) when (he/she) used it. I didn ' t look at the numbers on it (the spriometer). I didn ' t document (him/her) using it (the incentive spirometer). A face-to-face interview was conducted on February 20, 2013 at 11:00 AM with Employee #7. He/she acknowledged that the there was no evidence that the order for the use of [REDACTED]. The record was reviewed on February 20, 2013. |
2016-04-01 |