cms_GA: 3913
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 3913 | NORTHRIDGE HEALTH AND REHABILITATION | 115714 | 100 MEDICAL CENTER DRIVE | COMMERCE | GA | 30529 | 2016-11-03 | 514 | D | 0 | 1 | BL1O11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and record review, the facility failed to consistently document wound assessments to reflect measurements and staging of a pressure ulcer for one (1) of three (3) sampled residents (R) (R#187) with pressure ulcers. The sample size was twenty-five (25). Findings include: Staff interview on 11/01/2016 at 08:00 a.m. with Registered Nurse (RN)/Treatment Nurse AA revealed that R#187 had a terminal ulcer on right heel that was covered with eschar. The resident was receiving hospice services and was care planned for decline. The interview also revealed that the resident had an unstageable ulcer to the right lateral calf also along with multiple [MEDICAL CONDITION]. Review of the Treatment Administration Record (TAR) for R#187 revealed a wound to the right calf and right lateral foot. Neither wound was staged or identified as to type of wound. Review of Significant Change Minimum Data Set (MDS) assessment dated [DATE] revealed that R#187 was receiving Hospice Services, had a Brief Interview of Mental Status (BIMS) summary score of 10, indicating moderate cognitive impairment, was always incontinent of bladder and bowel and had active [DIAGNOSES REDACTED]. Observation and interview on 11/02/2016 at 10:10 a.m. of wound care for R#187 with RN AA revealed no concerns. The wound on the right heel was covered with eschar, it measured 2.5 x 2.5 centimeter. Wound on right MTPJ was covered with eschar, it measured 2.5 x 2 centimeters. The wound on the right lateral foot was covered with eschar, it measured 2 x 1.7 centimeters, the wound on the right ankle had been covered by an eschar cap but it has sloughed off according to the wound care nurse, the total area for this wound measures1 x 1 centimeters and the open area measures 0.5 x 0.5 centimeters. This area had a small to moderate amount of bright red bleeding, indicating that there was some blood flow. The wound to the right lateral calf was treated every other day and treatment was last done on 11/01/2016. Observation also revealed that resident had a pressure reduction mattress on the bed and heel boots were on the resident's feet prior to dressing change. Interview with RN AA revealed that R#187's appetite was very poor. Observation also revealed that resident was lying on his right side before and during treatment and that he kept his right leg drawn towards his body. RN, AA further revealed that the resident was able to straighten his leg but preferred not to straighten it and that he had been premedicated for pain. Review of Physician order [REDACTED]., right lateral foot, right heel, right ankle, right anterior foot-side of foot. Clean right lateral calf with Normal Saline, pat dry, apply Dakins soaked gauze to wound bed cover with dry dressing and secure with gauze wrap and tape every other day. Review of the Care plan for R#187 documented that resident was at risk for foot ulceration r/t [DIAGNOSES REDACTED]. Resident bends right leg up at times and pushes off heel lifts. Review reveals that there is an acute care plan for pressure ulcer. Interview on 11/02/2016 at 1:18 p.m. with RN AA and Treatment Nurse, Licensed Practical Nurse (LPN) BB revealed that there was a Corporate Wound Care Nurse Consultant who was available to answer their questions. Interview also revealed that the treatment nurses were responsible for identifying the type of wound that the resident had and staging pressure ulcers. RN AA stated that when they idenify the wound type and stage pressure ulcers that they call the physician and he verifies or clarifies their findings. Observation on 11/02/2016 at 2:20 p.m. revealed that R#187 was lying on his right side. Observation on 11/03/2016 at 10:00 a.m. revealed that the R#187 was lying on his (R) side. Review of Policy for Assessment of Wounds revealed that it was the responsibility of a licensed nurse to complete the wound assessment, identify the type of wound, and that pressure ulcers were to be staged. Assessment of the wound and surrounding areas were to be documented in the record. Interview on 11/03/2016 at 2:28 p.m. with Certified Nursing Assistant (CNA), CC revealed that R#187 required total assistance with all activities of daily living, he was turned every 2 hours but frequently refused to be turned or he would turn himself back to his right side. She stated that he wears lift boots to reduce pressure to his lower extremities and so she had to make sure he had them on and they were properly applied. Interview on 11/03/2016 at 2:52 p.m. with the Director of Nursing (DON) revealed that all the nurses were responsible for assessing wounds, but that treatment nurses were responsible for staging wounds. She went on to state that Treatment Nurse, LPN BB had received the ETHICA wound certification classes. She stated that Treatment Nurse, RN AA was new to the position as treatment nurse, having started the position in August, (YEAR). She also stated that Treatment Nurse, RN AA was scheduled to attend the wound care certification class. The DON stated that she would expect the wound care nurses to document the type of wound and if appropriate, the stage also. The DON stated that if the treatment nurses have questions regarding wounds that they can call the local wound care clinic, the physician, and the Corporate Wound Care Consultant, who was certified as a Wound, Ostomy, Continence Nurse. Review of Treatment Administration Record from July, (YEAR) through November, (YEAR) revealed that the wounds were not consistently identified as to type of wound or staging for wounds that the wound nurse verbally identified as pressure related wounds and that were observed to be wounds covered by eschar over bony prominences. | 2020-09-01 |