cms_HI: 12
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 12 | HILO MEDICAL CENTER | 125002 | 1190 WAIANUENUE AVENUE | HILO | HI | 96720 | 2019-12-20 | 686 | D | 0 | 1 | P3CE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview with staff members, the facility failed to ensure prevention of an avoidable facility-acquired pressure ulcer. Although the facility was conducting weekly skin assessments, the assessments did not identify skin issues prior to the emergence of a Stage 2 pressure ulcer to the coccyx. Also, the facility identified an abrasion to the right lateral knee as a result of a mechanical device, the interventions provided did not prevent the abrasion from progressing to a Stage 2 pressure ulcer. Findings include: On 12/18/19, a review of the facility's Resident Census and Conditions of Residents (CMS-672) found documentation of one resident with pressure ulcer (excluding Stage 1). The Facility Matrix provided by the facility on the morning of 12/17/19 did not document Resident (R)2 has pressure ulcer. R2 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Observation of the resident during the initial tour of the facility on 12/17/19 found R2 asleep in bed with noted right below knee amputation. On 12/20/19 at 07:57 AM, a record review was done. A review of the physician's orders [REDACTED]. R2 has a care plan to maintain skin integrity, prevent skin breakdown. The following care plan revisions include: 11/07/19 - monitor for presence of [MEDICAL CONDITION]; 11/25/19 - use skin sleeves to bilateral arms for skin protection and do treatment to my right lateral knee; 12/09/19 - turn me very hour when in bed, continue to do skin check routinely, and notify physician/wound nurse of significant findings; and 12/09/19 - continue to encourage to increase fluid intake as tolerated and if not indicated. On 12/20/19, observation at 09:40 AM found R2 asleep in bed (air mattress), the resident was placed on his/her back with legs raised behind the knees. At 10:10 AM, resident was observed in bed, in the same position. The hospice worker was visiting the resident. A request was made for documentation of skin assessments. On 12/20/19 at 09:43 AM, the facility provided documentation of the progress notes related to the R2's pressure ulcers. The note for 10/30/19 documents R2 has a prosthesis for the right leg which he/she applies independently. A Stage 2 pressure ulcer developed as the resident was placing a sock on before applying the rubber cushion for the prosthesis. The skin and weight note dated 10/31/19 documents a pressure ulcer to right lateral knee measuring 1 cm x 1 cm. At this time Glucerna was ordered to increase R2's protein intake. Also, R2 was willing to add [MEDICATION NAME] (protein supplement) to his/her diet. Subsequent note on 11/07/19 documents no change to measurement of the wound. R2 was consuming the Glucerna and [MEDICATION NAME] to promote wound healing. R2 also documented with pneumonia. A nursing note on 11/09/19 notes wound bed is pink with contracted edges and minimal sanguineous draining with no signs and symptoms of infection. The use of duoderm was discontinued and [MEDICATION NAME] with kerrafoam dressing was initiated. The subsequent assessment notes on 11/13/19 a decrease in the wound from 1 cm x 1 cm to 1 cm x 0.8 cm. The note on 11/28/19 found R2 with recent decline in conjunction with changes in mental status (more confused and disoriented). The note on 12/03/19 documents an increase in measurement from 1.0 cm x 0.8 cm to 1.5 cm x 1.0 cm. An alert charting for 12/07/19 notes R2 with an open area to the coccyx measuring 1.2 cm x 0.8 cm. The wound was covered with foam dressing and sensicare was applied. The plan was to reposition every two hours and to get an order for [REDACTED]. On 12/20/19 at 10:13 AM, an interview was done with Licensed Nurse (LN)6. LN6 reported R2 has been experiencing a decline. LN6 also reported R2 was applying the prosthesis independently and upon discovering the application was wrong, the resident was re-educated. LN6 reported the injury to the right lateral knee started as a skin abrasion on 10/16/19 and was treated as an abrasion. Inquired whether weekly skin checks would find any changes to residents' skin to indicate possible skin breakdown. LN6 further explained R2 used to be very active and independent with hygiene care and recently has been more dependent on staff. LN6 responded the weekly skin check would indicate changes and maybe R2's skin breakdowns may have been identified before breaking down to a Stage 2 pressure ulcer. LN6 also reported R2 is being admitted to hospice. On 12/29/19 at 10:43 AM, an interview and concurrent record review was done with the Director of Nursing (DON). A review of the weekly skin assessments was done with the DON. The Stage 2 pressure ulcer to the right lateral knee was first documented on 10/09/19. The Advanced Practice Registered Nurse (APRN) was notified and ordered to apply [MEDICATION NAME] every day for four days. On 10/19/19, R2 went home for an overnight trip. Subsequently on 11/07/19, R2 was sent to the emergency department. The documentation up to 10/21/19 refers to the wound as an abrasion. A referral to the wound as a pressure injury was first documented on 10/31/19 as a Stage 2 pressure ulcer. A review of the weekly skin assessments in (MONTH) prior to the identification of a Stage 2 pressure ulcer to the coccyx (12/07/19) documents no skin issues. The DON reported R2 is declining and has been referred to hospice. The DON recalled prior to the breakdown of the coccyx (12/07/19), R2 went home from 11/01/19 through 11/03/19 for a visit. | 2020-09-01 |