| 68 |
HALE MAKUA - KAHULUI |
125007 |
472 KAULANA STREET |
KAHULUI |
HI |
96732 |
2019-11-26 |
684 |
D |
0 |
1 |
6SOG11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interview with staff members, the facility failed to ensure a resident, Resident (R)93 with a wound was accurately assessed and based on the assessment, determine appropriate treatment and interventions for healing and prevention of further skin breakdown to maintain his highest practicable physical well being. The wound reportedly was erroneously assessed as a stage 3 pressure ulcer. The facility also failed to coordinate and provide continuity of care for R93 as evidenced by observation of not applying the heel lift boot at all times; using a half sheet to pull resident up to reposition (creating shear and friction); not following recommendation of the Advanced Practice Registered Nurse to place resident on right side while in bed, not having an OTC ([MEDICATION NAME]) available for treatment, and lack of interventions to decrease moisture while in the facility and during [MEDICAL TREATMENT] treatment. Findings include: Cross Reference to F641. Resident (R)93 was admitted to the facility on [DATE]. R93's [DIAGNOSES REDACTED]. R93 has history of skin breakdown to his right buttock, excoriation to the scrotum and also to his right outer ankle. R93 was identified on the facility matrix with a facility acquired pressure injury. A review of R93's comprehensive Minimum Data Set with an assessment reference date of 11/07/19 found in Section M. Skin Conditions, R93 was coded with a Stage 3 pressure ulcer, this pressure ulcer was not present upon admission/entry or reentry. On 11/25/19 at 01:33 PM the facility provided a copy of the Care Area Assessment (CAA) which was signed by Resident Assessment Coordinator (RAC)1 on 11/17/19. A review of the CAA notes R93 with a stage 3 pressure ulcer to the left buttock that initially started as shearing, but worsened. R93 noted to be incontinent of bowel and bladder, utilizing briefs to manage incontinence. R93 also requires extensive assistance with one to two person staff assist for bed mobility (how a resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture). R93 received [MEDICAL TREATMENT] three times a week, requiring him to sit for a prolonged period during treatment. R93 was also noted to have open wounds to the scrotum and right buttocks, which have healed. A review of the R93's care plan found interventions related to risk for skin breakdown and moisture associated skin damage due to bowel and bladder incontinence. The interventions included: use of pressure reducing cushion to wheelchair and alternating pressure mattress; reduce potential for shearing, friction, rub injury, or bruising during transfers, elevation and repositioning by using a turn sheet; activity staff will assist with repositioning and encourage good fluid intake; keep right lower extremity rotated outward with direct pressure off of right lateral malleolus while in bed, use the heel lift boot at all times; and offer assistance with toileting before a big event or outing. The clinical note dated 11/08/19 notes an interdisciplinary team meeting was done to address weight loss due to decreased oral intake. There is documentation of open wound to left buttock, scrotum and right shin. R93's [MEDICATION NAME] level was noted to be within normal limits. The team decided to provide Boost pudding at med pass once a day to promote wound healing. On 11/20/19 at 11:30 AM and 02:15 PM, R93 was observed lying in bed asleep. R93 was positioned on his back with a pillow placed under his right knee. On 11/22/19 at 11:37 AM, R93 was observed asleep, placed on his back with a blue bolster pillow under his upper right extremity. On 11/26/19 at 09:12 AM, R93 was observed lying in bed with his right leg bent at knee (v-shape) with a pillow placed under the knee and ankle. R93 had an elastic bandage on his right foot which extended above the ankle. Interview with Certified Nurse Aide (CNA)5 found the resident has a foam boot which is placed on for two hours and removed every two hours. CNA5 also reported R93 is repositioned every two hours. On 11/20/19 at 09:25 AM an interview was done with the Neighborhood Supervisor (NS)1. NS1 reported R93 has a stage 2 pressure ulcer to the left buttock and a stage 1 pressure ulcer to the right buttock, further reporting it started as excoriation. NS1 also reported R93 had a scrotal wound which has healed. NS1 explained the resident goes to [MEDICAL TREATMENT] and despite attempts to coordinate with them to offload, it has been difficult. A review of the wound assessment worksheets found an assessment dated , 06/17/19 of a stage 2 wound to the left inner buttocks measuring 0.8 cm (length) x 1 cm (width) x There was no documentation of wound assessments from 06/17/19 until 07/14/19. The assessment of 07/14/19 notes the wound deteriorating. There was no documentation of wound assessment from 07/14/19 until 09/17/19. The size of the wound increased to 3 cm (length) x 1.5 cm (width) x 0.1 depth. The resident's wound was noted to be a previous wound that is now open despite barrier cream administration. The wound was noted with scant serosanguinous exudate. On 10/01/19 the wound was documented to have improved, the treatment included cleansing with normal saline and apply [MEDICATION NAME] to affected areas. The wound deteriorated on 10/22/19, slough was noted. On 10/22/19 the wound noted to deteriorate, increased in size measuring 3.7 cm (length) x 5.2 cm (width) x Further review found a report dated 11/12/19, entitled (Facility Name) - Wound Care *Skin Integrity* Evaluation which documents the presence of a stage 3 pressure ulcer to the left buttock. The size was 16.00 cm (length) x 2.60 (width) x The last assessment dated [DATE] notes the wound measured 1.5 cm (length) x .75 cm (width) x A review of the APRN note of 09/23/19 notes the wound to the medial left buttocks worsening and R93 complaining of pain while sitting during [MEDICAL TREATMENT] treatment. Also noted the [MEDICATION NAME] was not available and house stock zinc oxide was being used. The APRN notes open wound is not over bony prominence, there is partial thickness to the wound, probably due to shearing. The plan was to use baza cream three times a day and as needed after peri-care until [MEDICATION NAME] is available. Further recommendations include: keep pressure off site by positioning on right side when in bed, may use bordered foam dressing for comfort during [MEDICAL TREATMENT] and continue to monitor. On 11/25/19 at 12:43 PM an interview was conducted with the Assistant Director of Nursing (ADON). The ADON reported the facility does not have a wound nurse. The ADON explained the assessment of 11/12/19 which documents a stage 3 pressure ulcer was done by the private supply vendor. The ADON reported the vendor is a certified wound nurse and makes recommendations for treatment. Inquired whether it is within the vendor's scope to assess wounds and did the vendor actually assess R93's wound. The ADON was agreeable to follow up. On 11/25/19 at 12:54 PM the ADON provided a copy of the service agreement by the vendor. At this time the ADON shared that she did not notice the resident was assessed with [REDACTED]. On 11/25/19 at 11:36 AM an interview was conducted with the APRN. The APRN reported R93 went out on pass with his family and returned with excoriation to the left inner buttock which is not a pressure ulcer as it is not on a bony prominence. The APRN explained the wound is on the inside of the buttock, the fatty part where the butt cheeks touch. Further queried whether a root cause analysis was done to determine the type of wound the resident has and what were contributory causes for the breakdown. The APRN responded it could be moisture associated skin damage. A subsequent interview was done with the ADON regarding the lapse of documentation of the wound. The ADON reported the lapse may have been attributed to the healing of the wound. And when the assessments started again, the wound may have presented itself again. On 11/25/19 at 03:30 PM, the NS1 now reports R93's wound started with moisture and the house barrier cream was used. The NS recalled the wound was noticed after the resident returned from a family visit. The NS confirmed the resident's family will provide peri-care during his visit. The NS stated she has been trying to work with the [MEDICAL TREATMENT] facility to assist in repositioning and providing incontinence care. The NS reported although R93 receives [MEDICAL TREATMENT], he continues to urinate. At this time, the NS1 was asked to clarify how are staff repositioning the resident to reduce shearing and friction. The NS explained a half sheet in the middle of the bed is being used and the sheet is pulled up to reposition. The NS further clarified the half sheet is different from using the bed sheet, decreasing friction and sheer. |
2020-09-01 |