| 4049 |
CAMBRIDGE POST ACUTE CARE CENTER |
115771 |
2020 MCGEE ROAD |
SNELLVILLE |
GA |
30078 |
2018-09-27 |
686 |
D |
0 |
1 |
0V3G11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and staff interviews, medical record review, and facility policy review, the facility failed to provide physician ordered care and services to two residents with pressure ulcers, Residents (R) #58 and R#330. The sample size was 31. The findings include: 1.Review of R#58's record indicated the resident's [DIAGNOSES REDACTED]. Review of R#58's Minimum Data Set (MDS) with an assessment review date (ARD) of 7/27/18 indicated under Section G Activities of Daily Living (ADL) that self performance for bed mobility was total dependence two person physical assist. Transfer self performance was total dependence with two persons physical assist. Self performance for dressing was total dependence with one person physical assist. Self performance for eating was total dependence with one person assist. Review of the Brief Interview for Mental Status (BIMS) indicated the resident had long and short term memory issues. Review of R#58's Medication Review Report signed by the doctor on 9/12/18 indicated the resident had an order started 3/16/18 for applying heel protectors to both heels when resident is in bed, every shift. Review of the 9/1/18 to 9/30/18 Medication Administration Record (MAR) showed Apply heel protectors to both heels when resident is in bed, every shift. Review of the MARs for the months of 4/2018 to 8/2018 showed that the use of the heel protector was each MAR and documented for three times a day. Review of the 4/16/2018 5:47 p.m. Skin/Wound Note showed Note Text: Stage 1 to left heel: resolved. Wound base 100% intact skin, no redness. Treatment was D/C. Continue to apply heel protectors to both heel for prevention. Review of a progress note dated 8/8/18 progress note unstageable wound reopened to right heel. Review of the Skin and Wound - Wound Assessment document dated 9/16/18 indicated pressure type of wound deep tissue injury to the right heel acquired in house. This document indicated the wound was new. The space for exact date was blank. The wound measurements included area 7.9 centimeters (cm) square by length 4.4 cm by width 2.5 cm. The wound pain portion of this assessment indicated cognitively impaired, breathing normal, no vocalizations, a smiling facial expression, body language was relaxed and the pain score was zero. The goal of care indicated healable. Progress was shown to be stable. During observation on 9/25/18 at 6:00 p.m., when R#58 was in bed being fed by Certified Nursing Assistant (CNA) RR the resident did not have on heel protectors. Interview with CNA RR, who was in the room feeding the resident indicated when questioned if the resident had anything on her feet under the bed linen. CNA RR indicated it did not look like she has anything on feet under the covers. During the observation of 9/26/18 at 8:45 a.m., CNA LL was in room just finished feeding the resident. CNA LL indicated she was new to the unit and did not know about the heel protectors. She raised the bottom of the cover over the resident's feet. The resident was wearing white athletic socks not heel protectors. CNA LL said they were just socks. Interview with the Director of Nursing (DON) in the A corridor on 9/26/18 at 9:00 a.m., indicated that the nurse was responsible to ensure protector boots were utilized. They should be on when the resident was in bed. Interview with Wound Care Nurse at the A hall nurses station, on 9/27/18 on 11:15 a.m., said the right heel started on 3/16/18 unstageable resolved on 5/4/18 came back on 7/31/18. It came back because she stays in bed too long. R#58 lays in bed more than 8 hours. Does have PO (physician's orders [REDACTED]. Pressure reopened the heel. The boot is to prevent pressure. 2. Review of the medical record for R#330 revealed the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the five day MDS assessment dated [DATE] revealed R#330 had a BIMS score of 15 indicating intact cognition. The resident was assessed to be a risk for pressure ulcers and having unhealed pressure ulcers. Two unstageable pressure ulcers covered with slough or eschar that were present on admission. the largest measuring 8.8 cm x 7.3 cm x 5.0 cm. In addition, the resident had one arterial or venous ulcer with no infection. R#330 was utilizing pressure reducing device and receiving pressure ulcer care including ointments and dressings. The resident was referred to the Wound Care Nurse (WCN). The resident required two-person physical assist for bed mobility, total dependence with two plus people for transfers, extensive assistance of one person for dressing and personal hygiene, and extensive assistance of two plus people for toileting. R#330 was assessed to have frequent mild pain. Review of the document titled Treatment Administration Record (TAR) dated (MONTH) (YEAR) contained a physician order [REDACTED]. Dress with abdominal pad and dressing two times daily. The TAR for (MONTH) (YEAR) revealed no treatments were provided on 9/13/18, 9/22/18, and 9/23/18. The remainder of the days from 9/7/18 through 9/24/18 contained documentation for treatments once a day but there was no documentation of treatments being provided twice a day. Review of the care plan revealed R#330 has a sacral wound and an affected area on the left ankle that has a potential for pressure ulcer development related to altered skin integrity and impaired mobility. Interventions included the following: -Administer medications as ordered. Monitor/document for side effects and effectiveness. -Administer treatments as ordered and monitor for effectiveness. -Assess/record/monitor wound healing every week. Measure length, width and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report improvements and declines to the MD. -Educate the resident/family/caregivers as to causes of skin breakdown; including: transfer/positioning requirements; importance of taking care during ambulating/mobility, good nutrition and frequent repositioning. -Follow facility policies/protocols for the prevention/treatment of [REDACTED]. Interview with R#330 on 9/24/18 at 11:20 a.m. in his room revealed he had a pressure ulcer on his bottom that would not heal. The pressure ulcer developed in (MONTH) (YEAR) while in the hospital recovering from a bad stroke. An observation was conducted of the wound care and dressing change for R#330 on 9/24/18 at 12:15 p.m. in his room with the Wound Care Nurse (WCN) and Licensed Practical Nurse (LPN) CC assisting. The WCN reviewed the physician orders [REDACTED]. As the WCN was removing the old dressing from the residents sacral wound, it was noted that the old dressing was dated with black ink reading 9/21/18. The right leg dressings also read 9/21/18. The WCN confirmed the dressings were dated for the previous Friday like they had not been changed over the weekend. The WCN revealed there are other nurses who work the weekends or days off that are supposed to be doing the dressing changes. R#330 sacral wound was the size of a clinched fist and the old dressing contained foul smelling tan discharge. The edges of the wound were beefy red. The WCN completed the wound care and dressing change without difficulty. Interview with Assistant Director of Nursing (ADON) AA on 9/24/18 at 12:40 p.m., at the D Hall desk, revealed it is his expectation that the weekend nurses are to perform wound care and dressing changes. If the nurse cannot get all the treatments done, then the nurse should tell the next shift. ADON AA further revealed that LPN DD worked extra hours over the weekend doing treatments. An interview was conducted with LPN DD at the treatment cart on C Hall on 9/24/18 at 1:10 p.m. LPN DD revealed nurses can sign up for extra hours on weekends as the treatment nurse. LPN DD stated I came in Saturday 9/22/18 at 8:00 p.m. to help with wounds. I was able to complete the A,B, and C Halls, but everybody was asleep on the D Hall, so nobody got done on Saturday. I reported it to the Staffing Coordinator (LPN EE) that everybody was asleep, and I left around 11:00 p.m. I came in Sunday 9/23/18 around 7:00 p.m. and I was able to complete some of the treatments on D Hall and I let Registered Nurse (RN) FF know which residents were not completed and I left around 11:45 p.m. LPN DD confirmed that R#330 wound care and dressing changes did not get completed on Saturday 9/22/18 or Sunday 9/23/18. Interview with the R#330 on 9/24/18 at 3:35 p.m. confirmed that his wound care and dressing changes did not get done over the weekend. He stated he didn't say anything Saturday but Sunday evening he told his nurse, but it still did not get done. An interview was conducted with the DON in her office on 9/25/18 at 5:15 p.m. The Administrator was also present during the interview. The DON revealed they have a treatment nurse that works Monday-Friday and every other weekend taking care of all the treatments. Sometimes there is a second nurse who will assist her. On weekends, the regular nurses who are off duty are allowed to sign up for extra shifts to do treatments and they usually work 8:00 a.m. -5:00 p.m., but sometimes they work 5:00 p.m. -10:00 p.m. They are supposed to perform all the treatments starting with major wounds and going to minor wounds. The DON stated We really don't have that many wounds to take care of. If the treatment nurse doesn't complete all the treatments, then she should let the regular cart nurse know or on weekends tell the supervisor. Once I found out on 9/24/18 about the missed treatments, I informed the primary care Nurse Practitioner (NP). The DON further revealed LPN DD was scheduled to work earlier in the day on the weekend, but she came in late. An interview was conducted with the Wound Care Medical Doctor (WCMD) at the D Hall treatment cart on 9/25/18 at 3:45 p.m. The WCMD revealed he makes rounds once a week on Monday or Tuesday and he has seen R#330 twice. The last visit he performed some debridement. When asked if he was informed that the resident did not receive treatments and dressing changes for two days over the weekend, he denied knowing the information. The WCMD stated I would prefer that the orders for daily treatment and dressing changes be followed. Observation and interview with R#330 on 9/26/18 at 8:50 a.m. in his room revealed him to be lying in bed on his left side with wedge behind him and an emesis basin on the bedside table. R#330 stated I've been vomiting since last night about 8:30 p.m. The Wound Care Doctor did some cutting away at my wound and removed some more dead tissue. Interview with the DON on 9/26/18 at 1:50 p.m. in the conference room revealed she knows R#330's treatments were to be done daily. After reviewing the orders, the DON confirmed that the physician's orders [REDACTED]. An interview was conducted with the DON, the WCN, and the NP (Nurse Practitioner) on 9/26/18 at 3:10 p.m. outside the conference room at their suggestion. The WCN stated The wound treatments for R#330 have always been once a day but I forgot to change the order in the system. The NP revealed her practice group followed the resident when he was at the Long-Term Acute Care (LTAC) facility. His treatments were down to daily and she relayed that to the WCN here at the facility, but the order wasn't changed to reflect that. The WCN stated I went in today and changed the order when the DON brought it to my attention. An interview was conducted with LPN EE on 9/27/18 at 9:15 a.m. in the Staffing Coordinator office. LPN EE revealed she worked the floor Saturday 9/22/18 from 7:00 p.m. to 7:00 a.m. and LPN DD was scheduled to come in at 5:00 p.m. to do treatments, but she did not come in until 7:00 p.m. or 8:00 p.m. LPN EE stated LPN DD left around midnight and she informed me that she did not get to the treatments on C Hall. LPN DD also informed me that she would return Sunday 9/23/18 to finish C Hall treatments. LPN DD never mentioned anything about not doing the D Hall treatments where R#330 resides. I assumed she meant she would come in early on Sunday 9/23/18 to finish the treatments because she was scheduled in the evening to do medication pass. I passed along the information to the day shift about the treatments on C Hall not being completed but again there was no mention of D Hall. I was still under the assumption that LPN DD was coming in early on Sunday to finish. LPN EE revealed that currently the facility is allowing off duty nurses to pick up extra hours by signing up for treatments. If there is not an extra nurse for treatments, then it is the floor nurse responsibility to do the resident treatments. Review of the facility document titled Wound Evaluation and Management Summary dated 9/25/18 revealed the WCMD performed surgical debridement to R#330 sacral wound. The wound was assessed as a Stage IV pressure ulcer measuring 7.5 cm x 5.5 cm x 3.5 cm and classified as improved. Review of the facility provided document titled Wound Management Program Assessment and treatment of [REDACTED]. Standards: It is the practice of this facility to ensure residents with pressure ulcers receive necessary assessment and treatment to promote healing, prevent infection, and prevent new ulcers from developing. |
2020-09-01 |