cms_GA: 6889
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| rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 6889 | OAKS - SCENIC VIEW SKILLED NURSING, THE | 115393 | 205 PEACH ORCHARD ROAD | BALDWIN | GA | 30511 | 2013-02-14 | 314 | D | 0 | 1 | P02P11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview the facility failed to provide timely assessments to pressure ulcers and provide treatment according to physician orders [REDACTED].#270) and failed to assess the effect of a device which had the potential to cause pressure and conduct timely assessments for a pressure area for one (1) resident (Q) on a sample of thirty-three (33) residents. Findings include: Review of the medical record for Resident #270 revealed the resident was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The resident was admitted to the facility with a soft non-removable cast in place on the right leg. Review of the Daily Nurses Notes indicated the resident went to the physician's office on 2/8/13. Further review indicated the cast on the right foot was removed at the physician's office and a removable boot was applied. The resident returned to the facility with orders to for skin care to the right ankle, foot and calf to be performed twice daily. There was no evidence in the medical record of an assessment of the right foot and leg upon return from the physician's office on 2/8/13. In addition, there was no evidence skin care or treatment had been performed to the leg as ordered by the physician. Review of the Daily Skilled Nurses Notes dated 2/9/13 indicated the resident complained of pain to the ankle. The boot was removed and a reddened area was noted to the inside ankle and outside bone of the right ankle. A dark area was noted to the top of the foot. The note indicated the boot was loosened and notation was made that area was to be monitored. Review of the medical record indicated no evidence of any additional assessment of the areas on the right foot and ankle and no evidence any type of treatment was performed to the area until 2/11/13. Review of the Skin Notes dated 2/11/13 indicated the boot was removed from the right leg and pressure areas were noted. The lateral area of the fifth toe had an area of suspected Deep Tissue Injury (DTI) measuring 1.5 centimeters by 1.5 centimeters and was dark purple in color The right heel had a Stage 2 Pressure Ulcer measuring 0.6 centimeters by 1.1 centimeters. The top of the right foot had on open blister which measured 3.0 centimeters by 3.8 centimeters by Observation of the on 2/13/12 at 11:00 a.m. with Treatment Nurse BB revealed an open area on top of the right foot presenting as a Stage 2 pressure ulcer, the area around the wound was reddened. A Stage 2 Pressure Ulcer was present on the right heel and an area was noted on the side of the 5th toe and was bluish-purple in color and presented as possible DTI. During an interview on 2/13/14 at 3:30 p.m., Treatment Nurse BB stated when she arrived to the facility on Monday 2/11/13, she was told the resident had a new walking boot on and was having more pain in the foot. She further stated she removed the boot she discovered the wounds. She confirmed she could find no evidence of assessments or treatments to the areas since the resident returned from the physician's office on 2/8/13. She confirmed she did not stage the area on the top of the foot because she was told by the family the area was a Fracture Blister. During an interview on 2/13/13 at 3:00 p.m. Licensed Practical Nurse (LPN) BB Stated she did not remove the boot after the resident returned from the physician on 2/8/13. She further confirmed she did not call the physician to clarify the instructions to perform skin care to the right ankle foot and leg twice a day. During an interview on 2/14/13 at 9:15 am the Director of Health Services (DHS) stated the expectation would be for the nurse to notify the physician for verification of the orders for the treatment and the nurse should have assessed the right leg and foot upon return to the facility after the cast had been removed. Review of resident Q's Admission Minimum Data Set ((MDS) dated [DATE] noted they needed extensive assistance for bed mobility; had one Stage 2 unhealed pressure ulcer on admission; and was at risk for pressure ulcers. Review of the clinical record revealed [DIAGNOSES REDACTED]. Review of labs dated 12/20/12 noted a Total Protein of 5.9 (normal 6.0-8.3), and an [MEDICATION NAME] of 2.6 (normal 3.4-5.0). Review of a right foot and ankle x-ray dated 02/04/13 revealed that the resident had sustained a [MEDICAL CONDITION] malleolus and distal fibula, with mild lateral subluxation of the distal tibia. Review of orthopedic physician's orders [REDACTED]. Review of a Grievances/Complaint Form dated 02/09/13 noted a family member of resident Q had complained that the boot was left on the resident all night. Review of Daily Skilled Nurse's Notes (NN) dated 02/09/13 revealed an untimed entry that the resident was observed with a raised blister to the lateral malleolus (ankle area), approximately 4 X 1.5 centimeters (cm). Further review of these NN at 10:00 p.m. revealed the resident was in bed with the brace to the right foot intact. Review of the Documentation of Wound Observation and Assessment Form dated 02/11/13 noted the resident was assessed as having a Stage II pressure ulcer to the right lateral ankle, measuring 5 cm by 3 cm by less than 0.2 cm. Review of the narrative portion of this form noted that on 02/11/13, the resident was noted with a velcro walking boot in place; the velcro boot was removed and replaced with a floating/soft blue boot. During interview with Licensed Practical Nurse (LPN) Treatment Nurse BB on 02/13/13 at 8:55 a.m., she stated that the blisterwas caused from the velcro walking boot, and on 02/11/13 she got an order to discontinue the walking boot and apply a soft boot. Observation of resident Q's lateral right ankle at this time revealed an L-shaped area that appeared to be a ruptured blister. At 9:15 a.m., LPN CC stated that when she discovered the blister on 02/09/13, she notified the weekend Treatment Nurse who dressed the wound, and that she continued to use the walking boot when the resident was out of bed. Upon further interview, she stated she did not call the physician to clarify continued use of the boot. During interview with Registered Nurse (RN) Unit Manager DD on 02/14/13 at 8:30 a.m., she stated that there was no documentation in the NN as to when the walking boot was delivered and/or applied, and that the order should have been clarified as to when to wear it. During interview with LPN CC on 02/14/13 at 9:03 a.m., she stated that resident Q's family member had told her on 02/09/13 that the boot was to be used for transferring and when out of bed only, but that she was not able to contact the orthopedic doctor to verify this because it was a weekend. LPN CC verified that the 10:00 p.m. NN on 02/09/13 noted that the resident was in bed, and the brace to the right foot was intact. During interview with Physical Therapist FF on 02/14/13 at 9:35 a.m., she stated that she applied the walking boot on 02/07/13, told the nursing staff to take it off when he/she went to bed, and to check the skin every two hours. During interview with LPN Treatment Nurse BB on 02/14/13 at 9:55 a.m., she verified that the weekend treatment nurse did not start a Documentation of Wound Observation and Assessment Form when the blister was discovered on 02/09/13, and that the measurements documented in the 02/09/13 NN were an estimate. Upon further interview, she stated that she would have contacted the physician due to the resident's history of poor wound healing for treatment orders and to see if he wanted to continue use of the walking boot. Review of the facility's Actual Loss of Skin Integrity: Stage II/Partial Thickness Wound Protocol noted to notify Physician and legal representative of any new areas; document area per Documentation of Skin and Wound Care policy; initiate or review care plan and review interventions and update as needed. During interview with RN Nurse Consultant GG on 02/14/13 at 10:45 a.m., she stated that the purpose for the walking boot must have been for stability, as the resident was non-weight bearing. Upon further interview, she stated that skin checks were done every two hours when a resident had a brace, but was only documented if a concern was found. She further stated that there was no facility policy and procedure related to routine skin checks for a resident with a brace/boot. | 2017-09-01 |