cms_HI: 96
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 |
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
96 | MALUHIA | 125009 | 1027 HALA DRIVE | HONOLULU | HI | 96817 | 2018-08-28 | 686 | D | 0 | 1 | QVE911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interview and review of facility policy, the facility failed to place a pillow between resident's feet to prevent pressure on her feet. This practice would put Resident (R) 73 at risk for developing a pressure ulcer (PU) on her feet. This deficient practice had the potential to affect the 4 residents identified by the facility to have pressure ulcers. Findings Include: On 08/22/18 at 10:06 AM during record review (RR) of R73's electronic medical record (EMR) noted R73 had documentation of recurrent open area on her right big toe dated 06/18/18. Reviewed R73's skin assessment dated [DATE] at 1304 found there was a PU that was unstageable that was acquired in facility. On 08/27/18 at 11:14 AM at R73's bedside, with licensed practical nurse (LPN)1, requested to see R73's right foot. LPN1 pulled back R73's blanket and sheet noted R73's right big toe was healed. LPN1 stated I will put a pillow when it was discovered that R73's feet were resting near each other, side by side, touching each other. Further RR found PU documentation on 08/14/18 stated PU was new but at bottom of documentation it stated under notes Wound RN assessed and seen-resolved. Record review (RR) found R73 coded for a stage 2 PU on her last annual Minimum Data Set ((MDS) dated [DATE]. It was noted on R73's care plan (CP) that she is at risk for skin breakdown due to vegetative state, incontinence and diabetes. R73's CP was in place for PU wound and foot care but no intervention listed to place a pillow between feet to prevent the development of a PU. On 08/27/18 at 11:55 AM interviewed Head Nurse (HN) 2 who stated staff should be placing a pillow between residents feet to prevent putting pressure on the foot/feet. Review of facility Skin Care and Pressure Injury Prevention policy stated D. Protection from Friction, Shear and Pressure 6. Use positioning wedges or pillows. 7. Suspend heels while in bed. Neither of these were done for R73 upon observation 08/27/18 at 11:14 AM, putting this resident at risk to develop another PU on her feet. | 2020-09-01 |