cms_ND: 33
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 33 | THE MEADOWS ON UNIVERSITY | 355024 | 1315 S UNIVERSITY DR | FARGO | ND | 58103 | 2018-06-28 | 686 | D | 1 | 1 | ROZG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > THIS IS A REPEAT DEFICIENCY FROM THE SURVEY COMPLETED ON 05/10/17 Based on information provided by the complainant, observation, record review, resident and family interview, and staff interview, the facility failed to provide the necessary care and services to prevent the development of pressure ulcers and promote healing, for 1 of 4 sampled residents (Resident #22) with pressure ulcers. Failure to evaluate risk factors that may impact the development/healing of a pressure ulcer, implement, monitor and modify interventions to reduce those risk factors, resulted in Resident #22 developing avoidable, facility acquired pressure ulcers and may result in the development of new ulcers. Findings include: The complainant identified Resident #22 was admitted to the hospital on [DATE] with multiple areas of skin breakdown. Review of Resident #22's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. During an observation on 06/26/18 at 9:45 a.m. two certified nursing assistants (CNAs), (8# and #9) assisted Resident #22 with perineal cares. While staff performed cares, Resident #22 called out in pain and moaned. His buttocks, peri area, and scrotum were excoriated, his penis reddened and ulceration noted to the foreskin. He had an indwelling foley catheter. Current physician orders [REDACTED]. A quarterly MDS (Minimum Data Set), dated 05/28/18 identified frequent incontinence of bowel and bladder, extensive assistance of two persons for bed mobility, toileting and total dependence for transfers. The current care plan stated, . Self care deficit as evidenced . hands on staff assist with bed mobility, transfers, toileting . Skin care: . At risk for alteration . related to incontinence . barrier cream to peri area, buttocks . observe skin condition with ADL(Activities of Daily Living) care daily - report abnormality . Although Resident #22 was identified as frequently incontinent of bowel and bladder, his care plan failed to address his incontinence and provide specific interventions to prevent skin breakdown. Review of a Braden Scale (an assessment for predicting pressure sore risk), dated 05/04/18 and 06/05/18, identified a risk for pressure ulcers. A facility policy on skin conditions/pressure ulcers, was requested and the facility provided a Skin Practice Guide Process Flowchart. Review of Resident #22's medical record identified facility staff failed to follow the process as indicated by the flowchart. Resident #22's progress notes identified the following: * 05/07/18 Groin is pink. Only documentation regarding skin condition for the month of May. The next entry, 33 days later identified: * 06/10/18 Open area on back of testicles, 1 cm(centimeters) x 1 cm. Open area on left buttocks returned. * 06/17/18 Excoriation on right and left buttocks. Skin red and firm. Redness blanchable. Redness and excoriation peeling. Some areas on excoriation has scant amount of thin/red drainage noted measuring approx 15 cm x 15 cm. Testicle red/firm/swelling. Redness blanchable. Wound located on right testicle 1 cm x 1 cm Edges approximated. Second wound located on right testicle measuring 2.5 cm x 1 cm. Edges approximated. Black eschar noted (tissue that adheres firmly to the wound bed or ulcer edges). Small open area on left testicle 1 cm x 1 cm. Edges approximated dark/pink/red tissue noted, scant amount of thin red drainage noted. Writer left Situation Background Assessment and Recommendation (SBAR) for Nurse Practitioner (NP) to assess areas. New order for ointment to apply topically 3 x/day and as needed (PRN) to buttocks, peri area and excoriation. * 06/18/18 Resident transferred to emergency department (ED). Blood sugar (BS) of 1085 and Sodium (Na) of 126. * 06/23/18 Resident returned from hospital. Wound recommendation was put in for wound on back of penis/testicle. Resident continent of bowel and bladder (B&B). Has a foley catheter. Uses a bedpan. Is incontinent of B&B at times. * 06/24/18 the progress note showed: 1) Open area right testicle- 1 cm x 1 cm, yellow slough present. 2) 2nd open area right testicle 3.5 cm x 2 cm. 3) open area left testicle 1 cm x 1 cm. 4) Excoriation noted left buttocks. 5) Rash noted on right and left groin - raised bumps zero drainage. 6) Open wound on top of penis/foreskin - 2 cm x 2 cm yellow slough present - scant amount red/thin drainage. * 06/24/18 Resident requested to stay in bed all shift, was repositioned at routine intervals. During an interview on 06/26/18 at 4:28 p.m., Resident #22's wife stated she is aware of him being left on a bed pan for an hour. She stated it happened about a month ago. She also indicated he was hosptalized on [DATE] for high blood sugar and an infection. During an interview on 06/28/18 at 11:15 a.m., Resident #22, who has a Brief Interview for Mental Status (BIMS) of 15 (cognitively intact), reported sometimes he is on the bed pan for a long time because he falls asleep and staff failed to check on him after they put him on the bed pan. During an interview on 06/28/18 at 4:00 p.m. regarding Resident #22's pressure ulcers/skin breakdown, the administrative nurses (#1) and (#2) provided no further information. | 2020-09-01 |