cms_GU: 77
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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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 77 | GUAM MEMORIAL HOSPITAL AUTHORITY | 655000 | 499 NORTH SABANA DRIVE | BARRIGADA | GU | 96913 | 2012-01-26 | 314 | G | 0 | 1 | J2NN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation , interviews, and record review, the facility failed to ensure that a resident who enters the facility without pressure sores does not develop pressure sores unless the individual's clinical condition demonstrates that they are unavoidable for one of 10 sampled residents, (Resident 4) and one of 5 unsampled residents (Resident (11); and failed to provide necessary treatment to promote healing and prevent infection for one of 10 sampled residents (Resident 6) a resident who entered the facility with pressure ulcers. Findings include: 1. Resident 6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident had a gastrostomy tube ([DEVICE]) for feeding and a urinary catheter for elimination. The resident required total assistance for activities of daily living (ADLs). The resident's family member was with the resident most of the time. Review of the facility Pressure Ulcer Management Policy # 6301-II C-15 identifies pressure ulcers as follows: Stage 1: An observable, pressure-related alteration of intact skin. Skin changes in one or more of the following parameters: a. Skin temperature (warmth or coolness) b. Tissue consistence (firm or boggy) c. Sensation (pain, itching) d. A defined area of persistent redness in lightly pigmented skin, whereas in darker skin-tones, the ulcer may appear with persistent red, blue or purple hues. Stage 2: Partial thickness skin loss involving epidermis, dermis or both. the ulcer is superficial and presents clinically as an abrasion, or shallow crater. Stage 3: full thickness skin loss involving damage to or necrosis of subcutaneous tissue that may extend down to, but not through underling fascia. The ulcer presents clinically as a deep crater with or without undermining adjacent tissue. Stage 4: full thickness skin loss with extensive destruction, tissue necrosis or damage to muscle, bone or supporting structures (e.g., tendon, joint capsule). Undermining an sinus tracts also may be associated with Stage 4 pressure ulcers. unstageable: When the wound is mostly covered with necrotic tissue, it can not be staged until it is debrided. During observations on 1/24/2012 at 1:30 PM, a licensed nurse (LN) and a certified nursing assistant (CNA) were providing care to Resident 6. The resident was positioned on her right side. The CNA removed the resident's soiled brief. The urinary catheter bag was attached to the right side of the bed, causing the catheter tube to pull from the resident's urethra over the stool and down to the collection bag. Neither the nurse nor the CNA were observed moving the collection bag to the left side of the bed, nearer to the resident and out of area where the staff were working. The CNA used hand that was gloved to clean the resident while pouring water with the other hand over the perineum and the catheter tubing- spreading the stool over the entire perineum including the opening of the urethra, which increased the risk of urinary infection and infection of the sacral pressure ulcer. After the area was cleaned, the nurse removed the dressing from a Stage 4 pressure ulcer on the resident's sacrum. She cleansed the wound, and dressed it as ordered by the physician; however when she tried to secure the dressing, she taped the lower end of the dressing very near the anus where the tape would not stick. The dressing was not secure to prevent fecal cross contamination. The staff stated they had completed the resident's care. Resident 6's heels were covered with socks and heel protectors (a foam bootie). The surveyor asked to see the resident's heels. The right heel had a black circular pressure ulcer with reddened area surrounding the ulcer. The measurements were 4.0 cm x 2.0 cm. The wound bed could not be visualized as it was covered with hard black necrotic (dead) tissue termed Eschar. No treatment was provided for the heel pressure ulcer. When asked why the heel wound was not treated the LN stated she did not know. When asked the Head Nurse, she stated she did not know, however she would contact the doctor to find out. When asked about the method of cleaning the resident, the CNA stated We do not have enough wash cloths to go around. When asked about the catheter pulling the CNA and the LN stated, We should have moved it to the other side. Review of the electronic medical record Wound Assessment revealed the following: 10/22/2011 - Right heel- Stage 1 pressure ulcer, size 1 cm Length (L) x 0.75 cm Width (W) appearance -black skin noted. Treatment- Heel protectors and elevate heels. Sacrum- Stage 3 pressure ulcer size 6 cm L x 7 cm W appearance - 70% red, 30 % brown. Treatment - wet to dry (dressing) with normal saline. 11/8/2011- Right heel- Stage 1 size 1 cm L x 1 cm W appearance - black hard necrotic. Treatment- heel protectors and elevate heels. Comment- improvement. However the size had increased and necrotic tissue was present. Sacrum - Stage 2 size 6 cm L x 4.7 cm W appearance - pinkish/read surrounding, serous (yellowish fluid) discharge center of the wound is yellow brown color. Treatment- wet to dry dressing with normal saline. The standard of practice is not to down Stage a pressure ulcer - 11/25/2011 - Right heel - Stage 2 size 2 cm L x 1 cm W appearance - blackish. Treatment heel protectors and leg elevated. Sacrum- Stage 3 size 6.5 cm L x 5 cm W appearance- center - yellow/surrounding red. Serosanginous (yellowish/bloody) drainage. Treatment- wet to dry dressing with normal saline. 12/16/2011 - Right heel - Stage 2 size 2 cm L x 2.5 W cm hard black scab. Treatment heel protectors and leg elevated. Note - patient unable to reposition leg. Sacrum- Stage 3 size 7 cm L x 5.5 cm W x 2 cm D (deep), appearance- center - pinkish/ grayish yellow. yellowish drainage, mild odor and with grayish necrotic tissue. Treatment- wet to dry dressing with normal saline. Reposition every 2 hours side to side. The type of treatment to the sacral wound was not changed despite evidence that the wound was getting worse. 12/22/2011 - Right heel - No assessment documented. Sacrum - Stage 3 size 5.2 cm L x 7.7 cm W x 2.5 cm D appearance pinkish with yellowish tissue - wound debrided. Treatment- hydrogen dressing. 12/31/2011- Right heel - Stage 2 size 2 cm L x 2.3 cm W, appearance blackish, hard and dry. Treatment elevate on the pillow, heel of the bed. Sacrum - Stage 4 size 5.2 cm L x 7.7 cm W x 3.2 cm D with 2.5 cm undermining at 8 o'clock. Appearance - pinkish with yellowish tissue, yellowish drainage, mild odor. Treatment- hydrogel and [MEDICATION NAME] dressing after cleaning with normal saline. 1/24/2012 - (Observed by surveyor) Right heel- Stage 2 size 4 cm L x 2 cm Appearance - black with reddish surrounding. Treatment: heel protector, heel off the bed. Comment both lower extremities elevated on the pillow. Sacrum - Stage 3 size 4.6 cm L x 6 cm W x 3 cm D. No appearance documented. Treatment - wet to dry clean with normal saline, [MEDICATION NAME] wash and hydrogel applied to inner area of the wound. The heel wound was unstageable due to the presence of eschar covering the entire wound. There was no documentation as to why the right heel wound was not treated. The sacral wound started out as a Stage 3 and progressed to a Stage 4 involving bone and muscle. Undermining was documented one time. Review of the laboratory reports for the sacral wound were as follows: A swab sample of the sacral wound drainage was collected on 12/29/2011 source: deep wound sacral decubiti Stage 4 - Culture and Sensitivity (C&S) final results dated 1/3/2012 showed infection with four multi-drug resistant organisms (MDROs) Pseudomonas aeruginosa, Cirtobacter freundii, Acinetobacter baumannii [DIAGNOSES REDACTED] pneumoniae. The resident had prior infections of the [DEVICE] site collected C&S 11/9/11 with [DIAGNOSES REDACTED] pneumoniae and Pseudomonas aeruginosa; Two urinary tract infection [MEDICAL CONDITION] collected C&S 11/16/11 with Escherichia coli (E.coli- an organism found in feces) and 12/6/11 with Pseudomonas aeruginosa; and Peripherally inserted central catheter (PICC-line) infection C&S collected 12/6/11 with [DIAGNOSES REDACTED] pneumonia. The sacral wound was infected 12/29/2011 with two of the bacterium found in three other sites of the body. Review of the Care Plan Conference Summary dated 12/5/2011 and 12/7/2011 revealed the resident had a stage 3 pressure ulcer on 12/5/2011 and 2 pressure ulcer on 12/7/2011. A summary of the Interdisciplinary care conference and the staff's recommendations were faxed to the physician on 12/9/2011. The summary did not include complete or accurate identification or treatment of [REDACTED]. There was no documentation of discussion of the location of the pressure ulcers, or the progression in size or the infections of the pressure ulcers or the treatment of [REDACTED]. Review of the facility Pressure Ulcer Management Policy # 6301-II C-15 under section III. Wound Prevention/Management Interventions part C. reads as follows: For patients who have a pressure ulcer, document on the weekly Braden Scale Assessment, or when there is a change in the pressure ulcer and intervene appropriately (based on the stage level of the wound), as follows: .Stage II - Air Mattress .[MEDICATION NAME] Cleansing Spray . [MEDICATION NAME] Cream (moisture barrier) .Duoderm, changed every 3 days or as needed, OR Transparent film dressing, changed every 2 days or as needed, turning schedule every 2 hours. Stage III - Air Mattress, .[MEDICATION NAME] Cleansing Spray .[MEDICATION NAME] Cream . Normal Saline wet to dry dressing 2-3 times per day, cover with gauze using [MEDICATION NAME] tampe to secure to skin. [MEDICATION NAME] gel (to keep wound bed moist and promote (new cell growth), cover with gauze using [MEDICATION NAME] tape to secure to skin .Turning schedule every 2 hours .Stage III with necrotic tissue .Santyl Ointment (enzymatic Debridement) daily application, cover with guaze using [MEDICATION NAME] tape to secure to skin. Stage IV- Same as Stage III. There were no guidelines for how to manage unstageable pressure ulcers. There were no guidelines for Deep Tissue injury. The facility did not follow their policy in using [MEDICATION NAME] Cleansing Spray, [MEDICATION NAME] Cream, Duoderm or Transparent film dressing for Resident 6's right heel Stage II pressure ulcer (This pressure ulcer was unstageable because it was covered with Eschar) The Facility did not follow their policy in using Santyl (or any other enzymatic [MEDICATION NAME] agent) for Resident 6's Sacral Stage III pressure ulcer when eschar formed. Surgical debridement ended up revealing a deep Stage IV pressure ulcer. 2. Resident 3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The hospital history and physical record dated 1/8/12 revealed the resident was admitted due to [MEDICAL CONDITION] Recent admission with urinary tract infection, dysuria and infected left leg. Urine cultures showed Escherichia (E.) Coli and leg wounds with heavy growth of pseudomonas aeruginosa (1/17/12). Review of the Patient Progress Notes record dated 1/12/12 revealed the left leg wounds were debrided. On the same day, the physician ordered wound care daily alternate wet to dry with [MEDICATION NAME]. On 1/23/12 at 3:10 pm, during the initial tour, Resident 3's left lower leg dressing was observed soaked with bright red drainage. The licensed nurse stated that the physician has just changed the resident's leg ulcer dressing at the bedside. The Wound Care Flowsheet dated 1/8/12 revealed the resident's left lower leg had an irregular size pressure sore with a length of 25 cm x 4 cm in width with sero-sanguinous, odorless drainage. On 1/24/12 the left lower leg Stage II pressure sore was described as pale/pink in color and measured 19 cm L x 6 cm W with no depth. On the same day, the flowsheet also revealed a new pressure area in the left ankle described as Stage II with a length of 1 cm x 1 cm in width, yellow in color, with no drainage and no odor. The management was to elevate the legs on a pillow, and wet to dry dressing as prescribed. On 1/25/12, in an interview, the morning charge nurse indicated that the leg treatments were done by the night shift nurses because wound treatment and dressing changes can be done after the showers. On 1/26/12 at 8:15 a.m. Resident 3 was observed up in wheelchair eating breakfast in the common dining room. Upon surveyor request, a treatment observation was done after the resident finished breakfast meal and returned to the room. The treatment nurse assessed the multiple sites of debrided pressure sores: Left inner leg with irregular shaped open areas: upper area measured 11.5cm L x 4 cm W x 1 cm in depth (D); the middle area measured 4 cm L x 2 cm W with undermining and lower area measured 9.5 cm L x 3 cm W. The Stage II left ankle pressure sore measured 1.5 cm L x 1.0 cm W The black eschar on the lower lateral side of the left ankle measured 3.0 cm L x 2.0 cm W A dry scab on the upper lateral side of the left ankle measured 05. cm L x 0.5 cm W After the treatment nurse measured the pressure sore areas, she indicated that accuracy in measuring the debrided areas was inconsistent due to irregular open areas. Also the three open areas were measured as one in length as documented in the wound care. However, the undermining in the middle portion of the left inner leg was not identified. The black eschar area in the left ankle was not identified in the assessment on 1/24/12, two days prior to assessment conducted by the day shift treatment nurse. On the same day at 9:30 a.m., the director of nurses (DON) was made aware of the inaccuracies of pressure sore assessments and observed the newly discovered black eschar on the lateral side of the left ankle. 3. Resident 11 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The initial assessment nursing notes revealed no skin breakdown. On 1/25/12 at 9 a.m. Resident 11 was observed during morning care rendered by a certified nursing assistant. During the bedbath, the resident's back had three areas of persistent redness: a raised reddened area in the mid-back, flat reddened area on the right side of the back and a blackish red abraded area on the sacrum. The licensed nurse indicated that A&D ointment is applied as a preventive measure, however, the CNA did not apply the ointment because it was unavailable. The nurses' notes dated 1/24/12 revealed that the certified nursing assistant notified the licensed nurse of redness on the buttocks, raised reddish patches on the sacral area. On 1/25/12 on 11 pm-7 am shift, a licensed nurse documented red raised area mid-upper back still present, hard to touch. Charge nurse (CN) made aware. On 1/25/12, the 7 am-3 pm shift nurses notes revealed a reddened tender area size-like a quarter still present at mid upper back. Notified CN. There was no documented evidence in the medical record that the physician was notified of the reddened skin areas at the back. On 1/25/12 at 4 p.m. interview with the resident's husband revealed a concern of the reddened raised area on the resident's back if it was a growing cyst. He was also concerned about the resident's peeling skin in the hands and feet from the allergic reactions incurred from antibiotics infused in the hospital. On 1/25/12 after discussions with the licensed nurse about Resident 11's skin condition, the charge nurse notified the physician and obtained orders for warm compress to mid-upper back. The physician also held the [MEDICATION NAME] and [MEDICATION NAME] doses for that day. 4. Resident 4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of initial assessment dated [DATE] identified the resident as totally dependent on staff with all activities of daily living except eating. The resident had surgery to repair the fractured left hip (open reduction internal fixation) on 12/18/11. The initial assessment identified the resident with frequent hip pain daily. The admission notes dated 12/21/12 at 22:41 revealed the resident had a surgical wound that measured 15 ? centimeters (cm) scar incision in the left hip/thigh and a sore in the left hand in between the second and third finger. The Braden scale for pressure sore identified the resident as moderate risk to develop pressure sores. Upon admission the resident did not have any pressure sores but the resident was bedfast and required moderate to maximum assistance. Review of the nurses' progress notes revealed that on 12/25/11, the left inner buttock 3 small 1-0.5 cm next to the sacrum, about an inch below it, small 0.5 cmx0.6 cm and the larger one at the bottom 2.0 cm L(length) x 1.0 cm W(width). dry, no drainage. Duoderm applied. The Wound Assessment form confirmed that on 12/25/11 , the resident's left inner buttock had an open area next to the sacrum, measured 0.5 cm. below the first 1.0 cm x 0.5 cm down below the next one 2.0 cm x 1.0 cm W On 12/29/11 the Stage II pressure sore in the left inner buttock increased in size 2.0 cm to 7.0 cm in length and from 1.0 cm to 4 cm in width. Also, on 12/29/11 two other pressure sores were identified: A Stage II pressure sore in the right inner buttock that measured 5 cm in length and 4 cm in width and Stage II pressure sore in the sacrum that measured 3 cm L x 0.5 cm W. On 1/25/12 at 4:00 p.m. the licensed nurse who documented the pressure sore discovery revealed that she reported the skin breakdown to the charge nurse and was verbally told to apply the Duoderm. Review of the physician's orders [REDACTED]. On 1/26/12 at 7:20 a.m., interview with the charge nurse revealed that she might have told the other licensed nurse to apply the Duoderm and she was not sure if Duoderm required a physician's orders [REDACTED].>Review of the plan of care dated 12/29/11 revealed the resident was assisted to turn to sides; explained to resident the importance of repositioning and turning to sides every two hours. The social service designee notes revealed the resident has mood problems, feisty and needs special approach. On 1/25/12 at 2:45 p.m. during a treatment observation, Resident 4's sacral pressure sore was noted dry without drainage. The treatment nurse stated that the other pressure sores healed because the resident started getting out of bed and goes to the courtyard most of the time. | 2017-01-01 |