| 20 |
BENEFIS SENIOR SERVICES |
275012 |
2621 15TH AVE S |
GREAT FALLS |
MT |
59405 |
2019-07-11 |
686 |
G |
0 |
1 |
01HJ11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to prevent and evaluate the cause of an avoidable, Unstageable pressure ulcer to the left heel, that led to the development of an additional Unstageable pressure ulcer to the right heel, and a reoccurring one to the left buttock, for a resident that was at high risk for pressure ulcers for 1(#1) of 42 sampled residents. Findings include: During an observation and interview on 7/8/19 at 1:54 p.m., resident #1 was sitting in her recliner with her heels resting on the bar to her side table. No interventions were noted to be place at the time for the prevention of pressure ulcers. Resident #1 stated her pressure wounds were from spending too much time in bed. During an interview on 7/10/19 at 2:29 p.m., staff member G stated the interventions for resident #1's pressure ulcers was heel lift boots, off loading heels, and a pillow to float heels. Staff member G stated resident #1 received [MEDICATION NAME] cream on her buttocks every shift and with toileting. Resident #1's heels were painted with [MEDICATION NAME] twice daily. During an observation on 7/11/19 at 10:07 a.m., resident #1 was sitting in her recliner, with both her heels resting on the floor, without a protective boot. Resident #1 was not sitting on a pressure relieving cushion in her recliner. During an observation and interview on 7/11/19 at 10:09 a.m., staff members G and I performed wound care with resident #1. Staff members treated resident #1's sacral wound, which staff member I stated was an Unstageable pressure ulcer, measuring 2.7 cm x 3.2 cm. Staff member I stated resident #1 tends to sit in her recliner often and should be using a pressure relieving seat cushion at all times. Staff member I then noted resident #1's seat cushion was in resident #1's wheelchair, not in her recliner. Staff members G and I were unable to explain how the pressure area had developed. Next, staff members G and I observed the wound on resident #1's left heel. Staff member I stated that the wound was a resolving blister, but since the bed of the wound could not be observed, it was diagnosed as an Unstageable pressure ulcer. Staff member G stated the measurements of the wound were 2.3 cm x 1.9 cm. The wound was a dark red/light brown color, with slight bogginess in the middle. Staff members I and G stated that resident #1 should always wear heel lift boots to help relieve pressure, except when ambulating. Staff members G and I then stated resident #1 also had a pressure ulcer on her right heel. Upon observing resident #1's right heel, staff members G and I stated this was also an Unstageable pressure ulcer with measurements of 1.9 cm x 1.8 cm. Staff members I and G were unable to verbalize the factors that led to the development of the pressure ulcer on resident #1's bilateral heels. After treating resident #1's right heel with [MEDICATION NAME], staff members G and I assisted resident #1 back to her recliner, lifted her heels on the foot rest of the recliner, applied foam boots to both heels, and positioned a pillow under resident #1's feet. During an interview on 7/11/19 at 8:57 a.m., staff member F stated resident #1 had a pressure sore on her left heel and did not recall how she got it. Staff member F stated resident #1 wanted pillows under her legs, and she had booties. Staff member F stated the other day resident #1 did not want her heels to touch the bed. Staff F did not mention using a care plan to know interventions are used for resident #1's pressure ulcers. During an interview on 7/11/19 at 8:58 a.m., staff member H stated she did not know how resident #1 had developed a pressure sore on her left heel, but the first time it was noted was on 7/4/19. During an interview on 7/11/19 at 9:26 a.m., staff member G stated the treatment order for resident #1 included: treating a left heel pressure ulcer with [MEDICATION NAME] and keeping the heel in a boot; and monitoring the sacral wound, which, according to staff member G, healed open to air (without a dressing). During an interview on 7/11/19 at 10:42 a.m., staff member G searched through resident #1's care plan, and stated she could not find interventions explaining the recommendations for pressure relieving devices (i.e. boots and seat cushion). During an interview on 7/11/19 at 10:50 a.m., staff member K stated there was no root cause analysis for resident #1's left heel pressure ulcer as noted on 7/4/19. Staff member K stated resident #1 should have an air mattress with a pump. Staff member K stated resident #1 had heel lift boots, and her seat cushion should have been under her at all times, even in her recliner. Review of resident #1's Braden Scale for Predicting Pressure Sore Risk, dated 6/10/19, showed, If the residents total is 18 or less, consider him/her at risk for a pressure ulcer development. Resident #1 scored a 15. Review of resident #1's admission note, dated 6/28/19, showed the presence of pressure ulcers to both buttocks but had no mention of pressure ulcers on her bilateral heels. Review of resident #1's Weekly Bath Day Assessment showed the following: -7/2/19 Skin interventions being utilized were, wound rounds, wound treatment, fluids, Foley catheter, education, wheelchair cushion, and protein encouraged. -7/9/19 Skin assessment in the comments showed, blackened area to L outer heel. -7/9/19 Skin interventions being utilized were, wound rounds, wound treatments, Foley catheter, [MEDICATION NAME], Rooke boots/float heels, turned/repositioned per policy, wheelchair cushion, and pressure reducing mattress. Review of resident #1's care plan showed the following: -6/28/19, At risk for breakdown. Turn and position as per policy guidelines or as directed. Monitor skin integrity weekly and when assisting with adl's. (sic) Notify charge nurse of changes. -7/1/19, Admit skin assessment 6/28/19 Left buttock: L: 1.4cm, W: 2cm, D: 0.1cm, Right buttock: L: 0.5cm, W: 0.4cm, D: 0.1cm. No mention of alteration of skin to either the right or left heel were noted in the skin assessment. -7/6/19, Left heel wound, identified on 7/4/19. The care plan had no mention of interventions that should be in place to prevent the worsening or development of new pressure ulcers. Review of resident #1's Interdisciplinary Notes showed the following: -6/10/19 resident #1 was admitted to the facility noted no pressure ulcer to left and right heel. -6/28/19 resident #1 was readmitted back to the facility with wounds to her buttocks. No mention of heel wounds were noted. -7/4/19 resident #1 was seen for wound rounds for buttock. Wounds to buttocks were open to air and deemed healed. (Resident #1) is noted to have foam heel protectors in place and when questioned she reports mild discomfort of her left heel. There appears to be a pressure sore, a dry blister that is unstageable and measures 3x4cm. Will paint with [MEDICATION NAME] BID and monitor. -7/9/19 resident #1 was noted to have a small blackened area to her right heel. Review of resident #1's Treatment Record showed, blister left heel paint with [MEDICATION NAME] BID heel lift boots in bed, initiated on 7/4/19. Family brought in heel lift boots on while in bed. Review of resident #1's wound care order dated 7/4/19, showed blister to left heel- paint with [MEDICATION NAME] BID- monitor. Heel lift boots in bed. Remind (resident #1) to have her family bring in a pair of heel lift boots. Review of resident #1's (Facility) Wound Alert dated 7/11/19 showed the following: -Right buttocks reddened area blanchable less than 2 seconds, cool and soothe with off loading using cushion on all surfaces. Left buttocks unstageable wound-dry scabbed area measures 2.7 cmx3.2 cmx0.1 cm with previous chronic scar tissue. -Right heel pressure sore unstageable dried eschar peri wound is blanchable within 2 seconds. measures 1.9 cm x 1.8 cm. Painted with [MEDICATION NAME]. -Left heel pressure unstageable dried dark area appears to be resolving, center of wound firm, 2.3 cm x 1.9 cm. Paint with [MEDICATION NAME] off load with heel foams at this time, family requested to bring in heel lift boots, not in room at this time. |
2020-09-01 |