cms_ND: 19
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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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 19 | THE MEADOWS ON UNIVERSITY | 355024 | 1315 S UNIVERSITY DR | FARGO | ND | 58103 | 2019-05-16 | 686 | G | 1 | 1 | FA2L11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > THIS IS A REPEAT DEFICIENCY FROM THE SURVEY COMPLETED ON 06/28/18. Based on observation, record review, review of facility policy, and family and staff interview, the facility failed to provide appropriate treatment and services to prevent the development and/or deterioration of pressure ulcers for 3 of 5 sampled residents (Resident #17, #30 and #31) with pressure ulcers. Failure to consistently implement interventions, ensure adequate monitoring/assessment, and complete wound care as ordered resulted in the deterioration of Resident #30's pressure ulcer, and delayed treatment/deterioration of pressure ulcers for Resident #17 and #31. Findings include: Review of the facility policy titled Pressure Ulcers/Skin Breakdown - Clinical Protocol occurred on 05/16/19. This undated policy stated, . In addition, the nurse shall describe and document/report the following, as applicable: a. Full assessment of pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissue . The physician may guide the care plan as appropriate, especially when wounds are not healing as anticipated or new wounds develop despite existing interventions. Review of the facility policy titled Repositioning occurred on 05/16/19. This undated policy stated, . The purpose of this procedure is to provide guidelines . to promote comfort for all bed- or chair-bound residents and to prevent skin breakdown, promote circulation and provide pressure relief for residents. Repositioning is a common, effective intervention for preventing skin breakdown, promoting circulation, and providing pressure relief. Positioning the resident on an existing pressure ulcer should be avoided since it puts additional pressure on tissue that is already compromised and may impede healing. - Review of Resident #30's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. The current Minimum Data Set (MDS), dated [DATE], identified no rejection of cares, extensive assistance from two or more people for bed mobility and two Stage IV pressure ulcers. Resident #30's current care plan stated, . Focus . I have potential for altered nutrition and weight changes r/t (related to) diuretic in use, presence of wounds . Interventions . Provide Regular diet with enhanced foods, double portions of protein and honey thick liquids as ordered . Provide supplements as ordered for wound healing. Focus . At risk for complications due to musculoskeletal problems r/t MS ([MEDICAL CONDITION]) . Interventions . Assist with bed mobilty . Focus . Resident has pressure ulcer(s) to right ischium related to: hx (history) of pressure sores, decreased mobility, MS, cardiac, and tendency to stay in one position per preference, resident chooses to set up longer in w/c (wheelchair) against the order to sit up only for 30 minutes for meals . Encourage and assist as needed to turn and reposition; use assistive devices as needed . Encourage resident to follow the limit time up in w/c and provide education about risk and benefit of following order or not following order. Pressure reducing surface on bed/wheelchair: Clinitron bed (sand bed) in use since (MONTH) 8th, 18 (2018) . Repositioning during ADLs (activities of daily living) . Resident has pressure ulcer(s) to left ischium related to: hx of pressure sores, decreased mobility, and tendency to stay in one position per preference, resident chooses to set up longer in w/c against the order to sit up only for 30 minutes for meals . Interventions . Adding yogurt to meal trays to try to improve intakes . Nurses' notes and wound assessments stated the following: *01/09/19 at 3:04 p.m.: . Pt. (patient) returned from appointment at (wound clinic). Left and Right Ischial ulcer: fill with Mesalt (a type of gauze dressing that uses a wicking action to cleanse draining wounds) and cover with [MEDICATION NAME] (a bordered foam dressing designed to minimize trauma to the wound and surrounding skin at removal) - change daily and PRN (as needed). Use barrier spray to peri (around) wound skin. Continue with activity orders - up for meals only (60 minutes only) and turn every 2 hours. *01/11/19 at 10:12 a.m.: . The unstageable pressure sore to the right ischium measures 2.0 x 2.0 x 0.3 cm (centimeters) (length x width x depth). The wound bed is 100% granulation tissue. No undermining/tunneling noted. The unstageable pressure sore to the left ischium measures 1.2 x 1.2 x 0.2 cm. The wound bed is 100% granulation tissue. No undermining/tunneling noted. Preventative measures in place include the use of the clinitron bed, keeping skin clean and dry, keep ischium wound sites off pressure, pressure reduction cushion in w/c (wheelchair), turning and repositioning regularly, assistance with meals, daily nutritional supplements, daily skin audit, and weekly skin assessment by nurse. *02/19/19: L ischium 1 cm x 0.8 cm x 0.8 cm, wound bed red and 100% granulation tissue, no undermining/tunneling noted, small amount serosanguinous drainage; R ischium 1.7 cm x 1.7 cm x 1.1 cm, wound bed red and 100% granulation tissue, tunneling at 7 o'clock, 2.2 cm, small amount serosanguinous drainage *03/07/19 (admission assessment post hospitalization ): L ischium 0.5 cm x 0.8 cm x 0.3 cm, no tunneling documented; R ischium 1 cm x 2 cm x 1.2 cm, no tunneling documented *03/13/19: L ischium 1.5 cm x 0.6 cm x 0.4 cm, no undermining/tunneling noted, small amount serosanguinous drainage; R ischium 1.2 cm x 2 cm x 1 cm, tunneling at 7 o'clock, 2.5 cm and 10 o'clock, 3.2 cm, small amount of sanguinous drainage *04/18/19: L ischium 0.5 cm x 1.5 cm x 0.8 cm, small amount of purulent drainage, periwound macerated; R ischium 1.2 cm x 1.2 cm x 0.8 cm, tunneling at 10 o'clock, 3 cm, moderate amount of serous drainage, periwound macerated *04/30/19: L ischium 1 cm x 1.5 cm x 1 cm, indicated wound was assessed at clinic on this day; R ischium 2 cm, 1.9 cm x 2 cm, indicated wound was assessed at clinic on this day *05/01/19 at 1:39 p.m.: . met for skin and wt (weight) review. Wound is stable, and treatment changed yesterday at wound clinic. Will offer Greek yogurt at meals. *05/15/19: L ischium 2.5 cm x 1.3 cc (sic) x 0.8 cm; R ischium 4 cm x 2.8 cm x 6.5 cm deep *The record identified staff failed to take measurements from 04/30/19 until 05/15/19 (15 days later). The wound clinic progress note stated the following: *04/30/19: . Patient was last seen by myself on 03/26/19. Last visit, Bilateral ischial ulcers were filled with mesalt ribbon, followed by [MEDICATION NAME] border foam dressings. Today, right ischial ulcer was not adequately packed, causing some peri wound skin maceration. Gauze and tape was also utilized by SNF (skilled nursing facility), not [MEDICATION NAME] borders as ordered. Assessment: . Decubitus ulcer of left ischium, stage 3 . Decubitus ulcer of right ischium, stage 3 . Plan: . Mesalt ribbon (fill wounds lightly but adequately) bilaterally, to cover with large [MEDICATION NAME] borders, use NO TAPE, [MEDICATION NAME] only. Change dressings daily and PRN. Wounds will not heal if not adequately packed - I wrote to SNF . Must use barrier spray to bilateral ischial wound with each dressing change to protect peri wound skin - I wrote to SNF . Continue with orders also given to turn patient every 2 hours when in bed, and for him to be up for meals only, for no longer than 60 minutes each time. Resident #30's treatment administration record (TAR) identified twice daily dressing changes (not daily as indicated by the wound clinic), and identified packing to the right ischial ulcer (not bilaterally as indicated by the wound clinic). During an interview on the afternoon of 05/14/19, a nurse (#19) stated Resident #30's skin has really improved since we stopped using tape, and she thought the wounds were healing. During an interview on the morning of 05/16/19, a nurse (#20) stated, Not yet, when asked if staff were packing Resident #30's left ischial ulcer. She further stated, I have a feeling we're going to need to start (packing the wound), and it's starting to get a little deeper. The nurse identified staff measure pressure ulcers weekly. Observation of the dressing changes on the morning of 05/16/19 showed the nurse failed to pack the left ischial wound. The nurse packed the right ischial wound and stated, It tunnels back. After completing the dressing change, the nurse stated to the CNA, We should leave him like that (on his left side) for awhile, get him off that right side. The nurse asked the resident, who agreed. Observations on 05/13/19 at 11:38 a.m., 12:28 p.m., 2:09 p.m., 2:50 p.m., 3:42 p.m., 4:47 p.m., 5:50 p.m., and 6:31 p.m. showed Resident #30 lying supine in bed with a pillow under his left hip (placing pressure on his right ischial ulcer for nearly seven hours). Observations on 05/14/19 at 7:51 a.m., 8:42 a.m., 9:08 a.m., 9:55 a.m., 10:39 a.m., 11:17 a.m., and 12:48 p.m. showed Resident #30 supine in bed (five hours). Certified nursing assistant (CNA) charting identified Resident #30 was up in his wheelchair for 45 minutes, charted at 10:41 a.m.; however, observations during this time showed the resident remained in bed. Observations on 05/15/19 at 8:47 a.m., 9:55 a.m., 10:37 a.m., 11:03 a.m., 11:41 a.m., 12:14 p.m., and 1:19 p.m. showed Resident #30 supine in bed (four and a half hours). Resident #30's medical record failed to identify repositioning records and/or refusals to be repositioned. Observations of the following meals showed staff failed to provide double servings of protein and/or yogurt as indicated in his care plan: *Noon meal on 05/13/19 (no double protein or yogurt) *Breakfast meal on 05/14/19 (no double protein or yogurt) *Noon meal on 05/14/19 (no double protein) The facility failed to consistently implement dietary inventions, reposition Resident #30 every two hours, and complete wound care as ordered by the wound clinic. These failures resulted in increased size/tunneling of Resident #30's ischial ulcers and subjected Resident #30 to the need for continued treatments of the open wounds. - Review of Resident #31's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. * 04/18/19 at 11:00 p.m. to 11:26 p.m.: . resident left dorsal foot area has open area, due to [MEDICAL CONDITION], skin cleaned and dressing applied . measurement on left dorsal foot 2 x 1.5 cm . resident left foot has pitted [MEDICAL CONDITION] +2, wear ACE wrap in AM and off at HS (hour of sleep) . has some redness around the wound . will continue to monitor. * 04/24/19 at 5:43 p.m.: . called physician to notify of ulceration and request new treatment. Cleanse ulceration to L (left) dorsal foot with NS (normal saline) once daily. Apply [MEDICATION NAME] to slough and cover with a dry gauze dressing daily. Review of the Weekly Pressure/Non-Pressure Wound Assessment form occurred on 05/16/19. This form dated 04/24/19 showed the following: * Number of stage 3 pressure ulcers: 1 * Most severe type of tissue: slough * Ulcer/wound measurements: Site: L dorsal foot, Length 4.9 cm, Width 5.0 cm, Depth 0.0, Stage III * Notes: Facility Acquired Stage 3 pressure ulcer to dorsal L foot. Nurse states resident ulcer presented as a ripple in the skin. Noted after ace bandage was removed. Ulcer is larger than initial presentation. Wound bed with large amount of purulent drainage. Periwound reddened. Resident denies pain to area. Ace bandage removed. MD (physician) updated of change in wound and new treatment ordered. Dietician also notified. The medical record lacked evidence of wound care or monitoring from 04/19/19 to 04/24/19 which resulted in worsening and delayed treatment for [REDACTED]. During an interview the morning of 05/16/19, an administrative nurse (#7) confirmed the medical record lacked documentation of wound monitoring/treatment and acknowledged Resident #31's wound deteriorated prior to physician notification. - Review of Resident #17's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. Physician orders included weekly skin assessment and treatment for [REDACTED]. Observation of Resident #17's right foot showed reddened areas with dark spots in the middle of four of his toes. Observation on 05/15/19 and 05/16/19 showed Resident #17's right foot and toes up against the foot board of his bed. During an interview on 05/15/19 at 1:40 p.m. Resident #17's wife stated she asked staff approximately a month ago about the toes. She voiced concern because he had lost one toe on his left foot due to an ulcer not healing. Staff told her the resident had to wait to see the podiatrist. The medical record failed to show facility staff completed skin assessments related to Resident #17's toes or implemented interventions to prevent ulcers to his toes. During an interview on 5/16/19 an administrative nurse (#1) confirmed the medical record lacked documentation and interventions, and/or treatment of [REDACTED]. | 2020-09-01 |