cms_ND: 55
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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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 55 | MINOT HEALTH AND REHAB, LLC | 355031 | 600 S MAIN ST | MINOT | ND | 58701 | 2019-06-11 | 686 | G | 1 | 0 | HFFF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on information received from the complainants, observation, record review, and staff interview, the facility failed to provide the necessary care and services to prevent the development and promote healing of pressure ulcers for 2 of 2 sampled residents (Resident #3 and #14) and 1 discharged resident (Resident #17) at risk of developing and/or with known ulcers. Failure to implement, monitor, and modify interventions to reduce risk factors and consistently provide treatment to prevent the development of new pressure ulcers and/or heal current pressure ulcers resulted in Resident #14 and #17 developing avoidable facility-acquired pressure ulcers and had the potential to result in other residents (Resident #3) developing skin breakdown. Findings include: Information provided by the complainants indicated nursing staff failed to consistently utilize physician ordered interventions in a timely manner to prevent and/or heal ulcers. Review of the facility policy titled Skin Management System occurred on 06/10/19. This undated policy stated, . Pressure Ulcers, Venous Ulcers, and Arterial Ulcers, and surgical sites will be documented on . form or EMR (electronic medical record). Use one form per wound. Wound progress is to be documented each week with measurement and wound descriptions. Daily treatments are also documented on the same form. Skin issues such as skin tears, bruises, rashes, abrasions,[MEDICAL CONDITION]. will be documented . - Review of Resident #14's medical record occurred on all days of survey. The Significant Change Minimum Data Set (MDS), dated [DATE], identified extensive assistance from two or more people for bed mobility, one Stage II pressure ulcer, and one venous and arterial ulcer. Right Lower Leg Resident #14's current physician order stated, .Wound to right lower extremity: Apply santyl ointment to dark eschar tissue. Apply hydrogel gauze over santyl (not on good tissue). Cover with non-adherent dressing. Wrap with gauze and with tape. Apply protective ointment to peri-wound area. Change daily. Wound nurse to follow (started 05/17/19) . Resident #14's progress notes showed the following: * 03/06/19 at 7:44 a.m. - Resident has a wound on lower right calf. cleansed with NS. Patted dry. TAO (triple antibiotic ointment) applied and covered . MD (physician) notified. * 03/06/19 at 12:43 p.m. - New orders for wound to lower right leg. Apply steri strips to wound, apply gauze and [MEDICATION NAME]. Change gauze and [MEDICATION NAME] BID (twice per day). * 03/08/19 skin assessments shows open area to right lower leg (RLL) 11 centimeters (cm) x 4 cm No further documentation regarding right lower leg until 05/04/19 *05/04/19 at 11:41 a.m. - Writer was dressing RLL and noted open areas that were weeping and swelling from ankle to mid-leg. Area is red, no warmth noted. MD notified via phone, ordered [MEDICATION NAME] over open areas, change MWF (Monday, Wednesday, Friday). Ace wraps to be put on from foot to mid leg and taken off at HS (night) . * 05/06/19 at 10:05 a.m. - Resident RLL (right lower extremity) continues to be weeping and writer noted bleeding. CNA (certified nursing assistant) reported foul odor when removing dressing for shower. Area is red, warm and tender to touch, no swelling noted . MD has been updated via fax. * 05/07/19 at 6:13 p.m. - . Dressing change to right lower lateral leg. Area is red, cool to touch et draining clear fluid . * 05/08/19 at 3:32 a.m. - Resident has a treatment to RLE (right lower extremity) for swelling and weeping . some redness present which may be related to dressing changes and ACE wrap. at (sic) this time RLE is not wrapped with bandage. Will continue to monitor and notify md of any changes or worsening. * 05/09/19 at 5:47 a.m. - . discoloration to area scattered. some redness and purplish skin present which may be related to dressing changes and ACE wrap. at (sic) this time RLE is not wrapped with bandage . Will continue to monitor and notify md of any changes or worsening. Review of record showed the doctor responded to fax on 05/09/19. The physician stated he/she would see the resident tomorrow (4 days after symptoms reported). * 05/10/19 at 12:37 p.m. - . Ulcer on right leg is red, with darken area small amount of clear fluids was seen draining at left lateral aspect of wound . * 05/10/19 at 7:21 p.m. - . rt lower leg wound- dakens wet to dry BID until healed . wound nurse to follow, [MEDICATION NAME] 100mg (milligrams) po (oral intakes) BID X 7 days. * 05/11/19 at 2:29 p.m. - Resident's ulcer on right leg is blackish in color . minimal serosanguineous drainage . * 05/12/19 at 11:07 a.m. - . Eschar/scabbing is resolving. Yellow purulent drainage . * 05/13/19 at 9:50 p.m. - . area has some debrided areas and some dark colored tissue . * 05/15/19 at 10:49 p.m. - Continues on an antibiotic for RLE wound. wound (sic) area is around lower ankle, dark tissue, with some small areas of debridement . * 05/16/19 at 2:43 p.m. - Order received from (doctor name) . apply santyl to dark eschar tissue, apply hydrogel gauze over eschar, cover with non-adherent [MEDICATION NAME] dressing, wrap with gauze and secure with tape . Wound nurse to follow. * 05/19/19 at 1:01 p.m. - . Wound on her right lower extremity drains has a serosanguinuous drainage, black skin tissue softens and easily removed. * 05/20/19 at 2:47 p.m. - . (doctor name) recommended resident be seen in the emergency department due to [MEDICAL CONDITION] . * 05/20/19 at 6:17 p.m. - Resident admitted to . Trinity Health hospital . * 05/24/19 at 11:28 a.m. - Resident returned to facility . New orders for [MEDICATION NAME] 250mg PO every other day x3 days . Right lower leg has minimal eschar and slough present, wound bed is pink . Review of Resident #14's Admission/Readmission Evaluation on 05/24/19 identified a Stage III vascular ulcer to right lower leg (front). The record showed no further documentation after 05/24/19 regarding the progress of the wound. Review of progress notes and skin/wound assessments identified the facility failed to document weekly measurements. Coccyx Resident #14's current physician order stated, . [MEDICATION NAME] to open areas on bottom. Change every MWF until healed (started 05/01/19) . Resident #14's progress notes showed the following: * 04/27/19 at 1:50 p.m. - Writer noted three open areas to resident's bottom. the (sic) first one measures 0.8cm x 1cm on the left buttock and the second one measures 0.5cm x 0.8cm on the left buttock, and the third one measures 0.4 cm x 0.5cm on the right buttock. Foam dressings applied. Writer also noted redness around anal area, calmo applied. Will update MD at this time and continue to monitor. * 04/29/19 at 9:31 a.m. - MD would like areas on bottom to be treated with [MEDICATION NAME], change every MWF . Physician's order to start [MEDICATION NAME] on 04/29/19 to the open area on bottom. Review of (MONTH) 2019 Treatment Administration Record (TAR) showed Resident #14's treatment failed to be started until 05/01/19. Review of progress notes and skin/wound assessments showed the facility failed to document weekly on the progress of the wounds including measurements and descriptions. Right Toe The current physician order stated, . Paint wound on RT 1st MTPJ (metatarsophalangeal joint) wound, with [MEDICATION NAME] and cover with a [MEDICATION NAME] type bandage change daily (started 02/28/19) . Resident #14's progress notes showed the following: * 02/19/19 9:17 p.m. - (Doctor name) here to round on resident, order rec'd (received) to continue [MEDICATION NAME] dressing to rt MTP joint ulcer until healed. Change every 3 days and prn. Appt with podiatry for evaluation. * 02/27/19 7:33 p.m. - Resident went out to a podiatry appt. (appointment) today, recommends paint wound with [MEDICATION NAME] and cover with [MEDICATION NAME] type dressing daily. No soaking. * 05/11/19 6:39 p.m. - .Ulcer on right phalangeal region . * 05/28/19 3:01 p.m. - Has vascular wound on her toe. Review of progress notes and skin/wound assessments identified the facility failed to document weekly on the progress of the wound including measurements and descriptions. - Review of Resident #17's medical record occurred on all days of survey and identified [DIAGNOSES REDACTED]. Right Second Toe The progress notes identified the following: * 12/06/18 at 7:00 a.m. and 12/07/18 at 10:13 a.m., Will update MD Resident rt (right) great toe (nail) came off during showers . her second rt toe has a 2 cm (centimeter) wt (width) by 1.2 cm Lt (left) pressure area. Skin is intact and without drainage. Site is red, resident denies sensation or pain . * 12/11/18 at 3:26 p.m., This nurse paged (physician) regarding resident sore toe. He ordered Keflex 500 mg (milligram) PO (by mouth) TID (three times per day) for 10 days. First dose given by this nurse. The facility notified Resident #17's physician five days after discovering the pressure area on her right second toe. The facility failed to notify Resident #17's physician in a timely manner, paging him five days after they discovered the ulcer on her toe. * 12/12/18 at 10:39 a.m., . Pharmacy called and reported a different dosage, Author contacted (Physician), and confirmed dosage with (Physician) and pharmacy . and at 8:48 p.m., Resident continues with Keflex abt (antibiotic) 250 mg po Tid x 10 days for infection [MEDICATION NAME] to right great toe nail bed where toenail came off . Right great toe nail bed is dark pink (and) without any drainage. Right 2nd toe distal joint has a 2 cm (W) (width) x 1/2 cm (L) (length) red area that blanches. Resident denies any pain to the toes . * 12/13/18 at 3:58 a.m., Resident great toe and distal middle toe assessed. No drainage, swelling or signs of infection observed. Resident denied pain. * 12/14/18 at 9:33 p.m., Resident continues with alert charting for infection to right second toe distal joint. Right 2nd toe is red with a small yellow hardened area to anterior aspect. No drainage. Site blanches. Resident denies having any pain. Right great toe nail bed . has no redness or drainage. * 12/17/18 at 9:18 p.m., . continues on Keflex . 2nd toe right foot distal joint has a red area with a firm yellow center that has a scab forming. No drainage. Area left OTA (open to air). Resident denies any pain or discomfort to the right foot (and) toes. * 12/18/18 at 9:07 p.m., . remains on Keflex . Right 2nd toe distal joint is slightly red (and) blanches with palpation. Center of red area has a small circular hard white area with scab forming. No drainage (and) OT[NAME] Resident denies any pain or discomfort to her toes. * 12/19/18 at 9:00 p.m., . continues with Keflex . Right second toe distal joint has a slightly red area with small circular yellow center with scab formed. No drainage. The care plan identified, . Date Initiated: 12/17/2018 . Infection of wound/skin (Right great toe) . Administer meds as ordered, Diagnostic tests as ordered, Maintain precautions as indicated, Obtain labs as ordered and notify MD of results, Record temperature as clinically indicated. Date Initiated: 12/19/2018 . Scab at right 2nd toe r/t (related to) friction, impaired mobility, diabetes . Administer treatment per MD orders, Diet and supplements per MD orders, Encourage and assist as needed to turn and reposition, use assistive devices as needed, Float heels as able, Follow up care with MD as ordered, Report evidence of infection such as purulent drainage, swelling. Localized heat, increased pain, etc. Notify MD PRN (as needed). Progress notes also identified the following: * 12/20/18 at 8:00 p.m., . continues with Keflex . Right 2nd toe is slightly red with small white center forming a scab. No drainage. no c/o pain to toe. * 12/21/18 at 4:16 p.m., Wound nurse assessed the open area to resident's right foot 2nd toe. The wound measures 1.1 cm x 0.9 cm. The wound bed contains 100% hard slough. No drainage. No odor. No c/o pain. The wound nurse recommends that the area be cleansed with normal saline. Apply Antisept, and wrap in gauze. Change daily. The facility failed to measure the wound for nine days. * 12/22/18 at 1:06 p.m., . continues with Keflex . Right 2nd toe is slightly red with small white center forming a scab. No drainage. * 12/25/18 at 8:00 p.m., . completed . Keflex . right 2nd toe distal joint has a small scab dry (and) intact (and) base of toe is slightly red (and) warm to touch. This note faxed to Dr. * 12/26/18 at 10:05 p.m., . Right 2nd toe distal joint has a small brown scab dry (and) intact. Base of right 2nd toe is slightly red (and) warm to touch. denies any pain or discomfort. The chart lacked evidence that the ulcer resolved, as staff failed to document further observations of the toe. The quarterly MDS, dated [DATE], identified the resident was at risk of developing pressure ulcers and had moisture associated skin damage. The physician's orders identified, Start Date 03/07/19 . Skin evaluation every Thursday AM, every day shift every Thu (Thursday) . The next set of progress notes addressing Resident #17's toe identified the following: * 03/10/19 at 9:49 p.m., Resident's daughter approached this recorder and stated, my Mom's toe is infected . On exam 2nd toe on rt foot is light red, no swelling noted, has a dry callous type lesion of DP (sic) joint area, no drainage noted, residents (sic) states it does not hurt . Callous is dry measures 0.9 cm x 1 cm. The facility failed to identify the observable changes to Resident #17's toe prior to family voicing their observations/concerns. * 03/11/19 at 2:54 p.m., . Resident has Dx (diagnosis) of [MEDICAL CONDITION] to right 2nd toe. New orders for . [MEDICATION NAME] 100 mg tab po Bid x 7 days . Apply [MEDICATION NAME] daily to right 2nd toe. The significant change MDS, dated [DATE], identified the resident was at risk of developing pressure ulcers and infection of the foot (e.g., [MEDICAL CONDITION], purulent drainage). A progress noted, dated 03/12/19 at 4:41 a.m., identified, . received first dose of [MEDICATION NAME] . Toe is [DIAGNOSES REDACTED] and slightly warm to touch. Skin is intact. No drainage noted. She stated only has pain when blanket is laying on the foot. Blanket was pulled back and she stated she had relief. and at 9:11 p.m., . Right 2nd toe is red (and) swollen. Anterior distal tip of toe has a small circular open area with no drainage. Resident denies any pain or discomfort to toe. The facility failed to measure the open area on the tip of Resident #17's toe. The care plan identified, . Date Initiated: 03/12/2019 . Infection of wound/skin (right 2nd toe) . Administer meds as ordered, Maintain precautions as indicated, Record temperature as clinically indicated. The care plan failed to address removing pressure from the top of Resident #17's feet. Progress notes also identified the following: * 03/17/19 at 2:52 a.m., . continues taking [MEDICATION NAME] . No drainage. Denies of (sic) any pain. Foot elevated while in bed. * 03/18/19 at 9:05 p.m., . took last dose of Doxycycine . Right 2nd toe is dark pink with small circular scab to the anterior tip of toe. No drainage. Resident denies any pain or discomfort. * 03/29/19 at 1:27 p.m., Received new order from podiatry . Continue [MEDICATION NAME] treatment to right second toe for 7 days then discontinue. * 04/03/19 at 11:19 a.m., Note received from (Physician) with addendum made to specify painful calluses and ulceration to right 2nd toe, left foot hammer toe deformity and callus the left big toe. * 04/09/19 at 6:03 p.m., Resident's daughter . concerned that resident's right 2nd toe diabetic vascular ulcer is not improving. I note that right 2nd toe has a very thick necrotic black 0.8 cm circular scab dry (and) intact. No drainage. Surrounding toe is slightly red. Right foot is slightly cool to touch with pedal pulses palpable. Resident denies any pain or discomfort to the right foot. ROM (range of motion) (and) sensation is intact to right foot (and) toes when palpated (sic). Daughter . requests that a f/u (follow up) appointment be made ASAP (as soon as possible) with podiatrist . Staff failed to identify the observable necrosis to Resident #17's toe prior to family voicing their observations/concerns. The facility failed to measure/assess the ulcer since it was first identified on 03/12/19. * 04/17/19 at 2:25 p.m., Made an appointment with . podiatry to see if resident scabbed to her right second toe can be debride (sic). Staff failed to schedule an appointment with Resident #17's podiatrist in a timely manner, contacting his office eight days after the family made their request. * 04/22/19 at 2:00 p.m., Resident returned from appointment with podiatrist . No new orders. Dr. report states improving [MEDICAL CONDITION] right 2nd toe. Continue observation . The only weekly skin review provided by the facility, dated 05/02/19, identified, Skin intact, dry. Four days later, a progress note, dated 05/06/19 at 1:41 a.m., identified, Medial right great toe is not blanchable, black in color, redness present at ankle to black area at base of the toe. redness measures 22 cm in length from above the ankle to base of toe. blackened area on toe is 5 cm x 2 cm. Areas between the toes are flesh colored. 2nd toe has 1 cm x 1 cm area previously noted to be discolored and is in notes from podiatry. 3rd toe has reddened area 1 cm x 1 cm right lowere extremity is warm and dry, no [MEDICAL CONDITION] present, dorsal part of foot is cool to touch as are the toes, reflexes in expremity and foot present. telephone order OK to transfer resident to ER and treat per family request. Family in facility requesting resident be transferred to hospital for eval and treatment related to recent [DIAGNOSES REDACTED] and discolored toe. On 04/09/19, staff described a very thick necrotic black 0.8 cm circular scab. The chart lacked documentation regarding the toe until 05/06/19, at which time staff described a blackened area on toe, is 5 cm x 2 cm. During an interview on 06/06/19 at 8:00 a.m., when asked questions pertaining to Resident #17's ulcer, a managerial nurse (#5) stated, Originally, it was due to pressure, then they decided it was a diabetic ulcer, and then it became necrotic. She was put on antibiotics when she went to the hospital. When asked questions pertaining to the facility's care expectations, the managerial nurse (#5) stated, What they were supposed to do was complete a weekly wound tracker. Every week the Nurse Manager measures pressure sores. I would assume they started a wound tracker as soon as they found the sore. They would document the size, color, drainage, and stuff. I couldn't find a weekly skin assessment either. The weekly skin assessment would catch any other type of skin issue, non-pressure sore. so we know it's there. The facility failed to: * Notify physician in a timely manner after discovering the ulcer on Resident #17's toe, * Accurately identify/document observations of the infected area, * Measure Resident #17's toe ulcer in a timely manner/weekly per facility policy, * Document if/when Resident #17's ulcer resolved, * Assess/identify observable color changes/necrosis on Resident #17's toe, * Care plan the need to remove pressure from the top of Resident #17's feet, and * Schedule an appointment with the podiatrist in a timely manner after discovering the necrosis on Resident #17's toe. - Review of Resident #3's medical record occurred on all days of survey. A Significant Change MDS, dated [DATE], identified a risk for pressure ulcer, no pressure ulcer present, pressure reducing device for chair, and pressure reducing device for bed. The current care plan, dated 04/10/19, stated, . resident has suspected deep tissue injury to buttock, coccyx area r/t (related to) immobility during recent hospital stay . The resident requires an APM (air pressure mattress)for her bed . Observation on 06/05/19, at 9:55 a.m., showed two CNAs (#3 and #4) assisted Resident #3 from the wheelchair to the bed, performed ADL's (activities of daily living) and exited Resident #3's room. Resident #3's air mattress pump was unplugged from the electrical outlet. The CNAs failed to assure the air mattress was on and fully inflated. During an interview on 06/06/19 at 9:05 a.m., an administrative nurse stated he/she would expect staff to make sure the air mattress was on and lying on the bed frame would create a problem because there is nothing soft to prevent the resident from lying on the steel frame. | 2020-09-01 |