cms_GU: 92
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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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 92 | GUAM MEMORIAL HOSPITAL AUTHORITY | 655000 | 499 NORTH SABANA DRIVE | BARRIGADA | GU | 96913 | 2010-09-17 | 314 | E | 0 | 1 | 7DPX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure that residents having pressure sores received the necessary treatment and services to promote healing, prevent infection and prevent new sores from developing for 4 of 10 sample residents (Residents 1, 2, 4, and 6). These failures have the potential to contribute to delayed wound healing or the development of new sores. Findings include: 1. Resident 1 is a [AGE] year old female admitted to the facility on [DATE]. Her admission [DIAGNOSES REDACTED]. The medical record indicated the family/resident was requesting end of life terminal care and that [MEDICAL TREATMENT] had been declined. On 9/16/10, a skin observation was completed and all the skin was intact. On 9/17/10, the medical record was reviewed with LN4. She acknowledged the wound assessment dated [DATE] reflected the previously documented stage II pressure ulcer was recorded as healed. Additionally, she validated the nursing care plan was still being implemented to prevent the development of new pressure ulcers. One of the interventions listed on the potential pressure ulcer care plan was "SNU (Skilled Nursing Unit) - Turn and Reposition every two hours." That is, the facility staff would be turning the resident every 2 hours to help prevent pressure ulcer development. On 9/18/10, the wound assessment data, nursing care plan and certified nurse assistant (CNA) turning schedule was reviewed with LN 5. She acknowledged the turning schedule indicated the turning was to occur every 2 hours. A review of the CNA turning schedule documentation from 8/16/10 to 8/29/10 indicated the resident was being turned every 4 hours not every 2 hours as identified in the nursing care plan. She also acknowledged that the CNA turning documentation from 8/30/10 to 9/11/10 reflected that there were periods where the records noted the failure to turn the resident or document the turning event for the resident. The Pressure Ulcer Management Policy dated September 1987 indicated the staff should "implement the written turning schedule changing position at least every 2 hours while in bed" which did not always occur for this resident as per the record review. 2. Resident 2 is a [AGE] year old male admitted on [DATE]. His primary [DIAGNOSES REDACTED]. He experienced the stroke on 7?26/10 and had made some recovery from a previous vegetative state. His medical record indicated he developed a sacral pressure ulcer prior to admission in to the facility and that the pressure ulcer was debrided on 9/02/10. Wound care was observed on 9/16/10 and the nurse described the stage IV wound to be improving after the debridement. On 9/17/10, the physician orders, nursing care plan and CNA turning schedule were reviewed with LN5. She validated that the physician's orders [REDACTED]." The nursing care plan indicated one of the interventions listed on the pressure ulcer care plan was "SNU - Positioning intervention as turning and repositioning the client. The intervention did not reflect that the patient would be turned every 2 hours to help promote would healing and prevent additional pressure ulcer development. After reviewing the CNA turning schedule documentation from 8/18/10 to 9/16/10, LN5 acknowledged the turning records did not always reflect that resident 2 was turned every 2 hours. She also acknowledged that the CNA turning documentation reflected there were periods where the records demonstrated there was a failure to turn the resident or there was failure to document the turning event for the resident. The pressure ulcer management policy dated September 1987 indicated the staff should "implement the written turning schedule changing position at least every 2 hours while in bed" which did not always occur for this resident. 3. Resident 7 was admitted to the facility on [DATE] with several [DIAGNOSES REDACTED]. Nursing admission notes dated 9/05/10 described Resident 7 as "alert and oriented (times) 2;" that she was "verbally responsive but confused;" and that she was incontinent of bowel and bladder functions and was "using adult diaper." Review of the medical record revealed that Resident was admitted with a wound on the left lateral knee. A wound assessment dated [DATE] described the would as being a stage 2 with a length and width of 3 cms by 3 cms respectively. The wound was also noted as being "pinkish" with "serosanguinous" drainage. A nurses note dated 9/05/10 also noted that the resident had a "pressure sore on left lateral knee 3 cm X 3 cm." Accordingly, the wound was cleaned with saline solution and Duoderm (a moisture barrier occlusive dressing) was applied. On 9/05/10, a physicians order to apply DuoDerm to the left lateral knee was made. The same order noted to have the Duoderm changed every 72 hours. While a care plan dated 9/05/10 required staff to "assess, document, or report skin status or any appearance or blister or redness," further record review however revealed the lack of evidence of continuing assessment as a basis for determining if the treatment regimen and other interventions were effective or needed to be adjusted. On 9/17/10 at 9:35 a.m. wound care observation was made. While the left lateral knee dressing was removed by the treatment nurse, there was no Duoderm applied to the wound so that bleeding was noted around the edges of the wound. During the procedure, the treatment nurse stated that the wound should have been covered by Duoderm as was currently ordered by the physician. 4. Resident 6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 9/15/10 at 10:20 a.m., during the initial tour, the Resident 6 went out of the facility for her [MEDICAL TREATMENT] treatment in an acute hospital facility. The resident room had contact isolation precautions posted outside the door. Interview with the licensed nurse indicated that she was not sure of the cause of isolation. The licensed nurse added that the resident has either (MRSA) [MEDICAL CONDITION]-resistant staphylococcus aureus or (MDR) multi drug resistant infection from the wound in the right stump. A review of the MDS dated [DATE] revealed that Resident 6's cognition was moderately impaired and with periods of lethargy, e.g. sluggish staring into space, difficult to arouse with little body movements. The resident was identified with two (2) pressure ulcers, one of which was described as Stage II pressure ulcer. The skin treatments listed in the MDS were turning/repositioning program, nutrition or hydration intervention to manage skin problems, surgical wound care, application of dressings other than feet, application of ointments/medications (other than feet) and other preventative or protective skin care (other than feet). The resident's MDS also described infection of the foot - [MEDICAL CONDITION], purulent discharge, open [MEDICAL CONDITION] of the foot, received preventative or protective foot care (e.g. used special shoes, inserts, pads, toe separators), and application of dressings (with or without topical medications) The admission nurse's notes dated 7/15/10 at 23:30 stated that Resident 6 had a "Duoderm dressing over the sacral area which was still new. Size is small. Did not open it anymore." The wound assessment form dated 7/15/10 - 9/16/10 described the Stage II pressure ulcer in the sacral area that initially measured 2.0 cm long and 1.0 cm wide with no depth, odor or drainage on 7/29/10. As of 9/12/10, the Stage II pressure ulcer measured 5.0 cm long and 4.0 cm wide with no depth, odor or drainage. The nurses notes dated 8/9/10 at 1715 read: "Back from [MEDICAL TREATMENT] via hospital transport ...Dressing soaked with urine. Dressing of sacral wound changed." Nurse's notes dated 7/30/10 at 1800 stated: "Back from [MEDICAL TREATMENT] via hospital transport ...Cleaned and kept comfortable." On 9/14/10, the physician ordered wet to dry dressing with normal saline solution daily to sacral area. On 9/16/10 at 3:30 p.m. a licensed nurse was observed changing the dressing on Resident 6's pressure ulcer in the sacral area. The resident had to be cleaned twice due to bowel incontinence. The licensed nurse identified the pressure ulcer as Stage II with areas of pink and white. Wet to dry dressing with saline was applied in the sacral area. There was no in-depth assessment of the factors that led to the increase in the size of the Stage II pressure ulcer in the sacral area. | 2014-12-01 |