| 11269 |
AINSWORTH CARE CENTER, LLC |
285142 |
143 NORTH FULLERTON STREET |
AINSWORTH |
NE |
69210 |
2014-12-02 |
309 |
H |
0 |
1 |
ZQ0211 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER: 175 NAC 12-006.09D2 Based on observations, record review and staff interview; the facility failed to provide care and treatment to promote healing of wounds for Residents 17, 28, and 35. Facility census was 33. Findings are: A. Review of facility policy for Actual Impaired Skin Integrity (no date indicated) revealed residents with impaired skin integrity as a result of pressure ulcers, vascular ulcers, rashes, skin tears, surgical sites and diabetic/neuropathic ulcers were to receive interventions which included the following: -Medications and treatments as ordered -Encouragement and assistance to turn and reposition every 1 - 2 hours -Measure/assess wound and skin check every week -Notify physician of signs and symptoms of impaired skin integrity -Notify physician as needed for lack of response to treatment if no improvement noted within 2-4 weeks as indicated/appropriate -Monitor status of surrounding skin every day and notify physician as needed of noted impairment -Monitor for signs/symptoms of infection or other complication and notify physician as needed B. Review of Resident 17's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 10/27/14 indicated the resident was admitted to the facility 2/19/14 with [DIAGNOSES REDACTED]. Review of Resident 17's Treatment Flowsheet (a record of treatments provided by nursing) for 2/2014 revealed a physician's order dated 2/19/14 for saline wet-to-dry dressings (A gauze pad soaked in saline and placed on the surface of a wound bed, followed by a dry dressing pad placed on top of the wet dressing) to left lateral ankle BID (2 times daily) at 10:00 AM and 10:00 PM. Documentation revealed the 10:00 AM dressing change to Resident 17's ankle was not documented from 2/19/14 to 2/25/14 (6 of 13 dressing changes in 7 days). Review or Resident 17's Care Plan dated 2/25/14 indicated the resident had an open wound to the left lateral ankle and included the following interventions: - dressing changes 3 times weekly by Physical Therapy (PT) assisted by the Case Manager (a nurse employed by the facility), - area monitored by PT and Case Manager, - area measured by PT with every dressing change, and - measure the area weekly with skin assessments and document. Review of Treatment Flowsheets dated 2/2014 and 3/2014 revealed the 10:00 AM dressing change to Resident 17's ankle was not documented on 2/26/14, 2/27/14 and 2/28/14, and the 10:00 PM dressing change was not documented on 2/27/14, 2/28/14 and 3/5/14 (6 of 16 dressing changes in 8 days). Review of a Visit Summary by Resident 17's physician dated 3/5/14 indicated an order to continue dressing changes BID, and "should be as close to q (every) 12 hours as possible". The physician further ordered the wound to be measured weekly. Review of Treatment Flowsheets for 3/2014 and 4/2014 revealed the following: - On 3/5/14 the wound measured 5.4 cm (centimeters) x (by) 2.2 cm (This was the first documentation of the size of the wound since the resident was admitted on [DATE].) - The wound was measured weekly on 3/12/14, 3/19/14, 3/26/14 and 4/2/14 with a decrease in size noted. - There was no documentation of measurement of the wound after 4/2/14. - The 10:00 AM dressing change was not documented on 17 of 56 days, and the 10:00 PM dressing change was not documented on 3 of 56 days (20 of 112 dressing changes in 56 days). Review of PT Evaluation and Daily/Weekly Progress Notes dated 2/20/14 through 5/22/14 revealed no evidence to indicate PT measured the wound or completed dressing changes 3 times weekly. Review of the Treatment Flowsheet dated 5/2014 revealed the following: - Measurements of Resident 17's wound were not recorded. - The 10:00 AM dressing change was not documented on 3 of 5 days from 5/1/14 through 5/5/14. - Documentation indicated "new times start 5/6/14", and the morning dressing change was to be done between the hours of 6:00 AM and 2:00 PM and the evening dressing change between the hours of 6:00 PM and 11:00 PM. - From 5/6/14 through 5/31/14, Resident 17's morning dressing change was not documented on 6 of 26 days, and the evening dressing change was not documented on 1 of 26 days (7 of 52 dressing changes in 26 days). - There was no documentation to indicate the actual time of the dressing change within the ranges specified in order to assure a 12 hour interval between dressing changes as recommended by the physician. Review of Resident 17's medical record revealed no physician's order to change the timing of dressing changes. Review of a Referral Form dated 6/2/14 indicated Resident 17's wound to the left lower leg was treated since admission and had improved, however, "in the last week it has declined and the overall size has increased". A physician's order was obtained for PT to evaluate and treat the resident's wound. Review of a Wound Assessment Tool completed by the PT and dated 6/4/14 indicated Resident 17 ' s wound on the left lower leg measured 4.7 cm x 1.6 cm x 0.1 cm (depth). This was the first recorded measurement of the wound since 4/2/14 and represented an increase in size of the wound. The PT recommended daily wound dressing changes to be performed by nursing staff using [MEDICATION NAME] gauze or xeroform gauze (non-adhering mesh dressings used to treat wounds) to the wound bed followed by a non-adhesive pad, cotton bandage and tape. Documentation indicated PT would inspect the wound weekly and make further recommendations as needed. Review of an Addendum to Wound Assessment Tool completed by PT and dated 6/5/14 revealed PT would work with Resident 17 on left lower leg wound care 3 times weekly for 4 weeks. Documentation further indicated PT would provide guidance and instruction to nursing staff regarding wound care and dressing changes for the days PT did not perform the wound care. Review of the Treatment Flowsheet dated 6/2014 indicated the following: - Beginning 6/8/14 the dressing change would be done 3 times weekly on Monday, Wednesday and Friday by PT, and nursing was to complete dressing changes on the other 4 days of the week to assure daily dressing changes were completed. - There was no evidence to indicate nursing staff changed the dressing on Thursday 6/12/14, Saturday 6/14/14, Sunday 6/15/14, Thursday 6/19/14, Saturday 6/21/14, Sunday 6/22/14, and Thursday 6/26/14. Review of Daily/Weekly Progress Notes by PT dated 7/1/14 through 7/30/14 revealed PT performed wound dressing changes and measurements 3 times weekly. Review of Nursing Progress Notes dated 7/1/14 through 7/31/14 revealed nursing staff performed the wound dressing 1 time on 7/19/14 (which indicated the dressings were not changed daily as ordered). Review of a PT Discharge Summary dated 7/30/14 indicated Resident 17's left lower leg wound measured 3.0 cm x 1.1 cm x 0.1 cm which was a decrease in size. Review of the Treatment Flowsheet for 8/2014 revealed a physician's order dated 8/1/14 to dress Resident 17's leg wound as recommended by PT. The physician's order included the following: -Change the dressing every other day (qod) -Measure and document the wound length, width and depth qod -Cover the wound bed with [MEDICATION NAME] (a type of dressing used to treat wounds) cut slightly smaller than wound margins to allow granulation tissue (new tissue that forms on the surface of a wound during the healing process) to close inward -Cover the [MEDICATION NAME] with [MEDICATION NAME] (a non-adhesive dressing) and secure with kerlix (a gauze dressing) and Ace wrap (an elastic bandage) Review of a Medication Error report dated 8/5/14 revealed Resident 17's treatment to left lower leg was incorrectly performed by nursing staff on 8/3/14. Documentation indicated the wound measured 5.0 cm x 3.0 cm x 0.1 cm (an increase in size from measurements 7/30/14) because the [MEDICATION NAME] was not cut smaller than the wound margins as instructed, and therefore, "ruined healthy healed skin surrounding" . Documentation on the Treatment Flowsheet revealed the dressing change was performed qod except Friday 8/29/14. Review of Weekly Skin Integrity Action Tool (skin sheet used by nursing to document assessment and measurements of wounds) for 8/2014 revealed the following: -Resident 17's wound was not measured and assessed qod with dressing changes as ordered as no measurements were recorded on 8/1/14, 8/3/14, 8/7/14, 8/9/14, 8/11/14, 8/17/14, 8/21/14, 8/23/14, 8/25/14, 8/29/14 and 8/31/14. -The wound measured 3.2 cm x 1.7 cm on 8/13/14 and 4 cm x 2.4 cm on 8/27/14 (the depth of the wound was not documented) -The size of the wound had increased Review of the Treatment Flowsheet for 9/2014 indicated a physician's order dated 9/3/14 to change the treatment to saline wet-to-dry dressings to left lower leg wound BID at 7:00 AM and 8:30 PM. Documentation indicated the dressing change was performed BID from 9/3/14 through 9/15/14. Review of Weekly Skin Integrity Action Tool for 9/2014 revealed Resident 17's wound was not assessed or measured by nursing staff. Review of a PT Evaluation form dated 9/15/14 revealed Resident 17's leg wound measured 3.4 cm x 1.8 cm x 0.1 cm. Documentation further indicated the wound was being treated by nursing staff per PT recommendations, however, the treatment "was not followed exactly" . During interview on 12/1/14 at 5:00 PM, the Director of Nursing (DON) verified wound dressing changes on Resident 17's left lower leg were not performed in accordance with physician's orders and PT recommendations. The DON further verified assessments and measurements of the resident's wound were not completed by nursing staff in accordance with the plan of treatment. C. Review of Resident 28's MDS dated [DATE] revealed [DIAGNOSES REDACTED]. Review of a facsimile (fax) dated 11/21/14 at 7:52 PM revealed Resident 28's physician was notified of a "...burn from hot coffee." The resident spilled coffee and sustained reddened skin areas on the inner left thigh from groin to knee and a 3 cm area on the left inner foot. Cool water was applied to the site followed by [MEDICATION NAME] (topical cream used to treat burns). Documentation further indicated 45 minutes later the redness to the resident's inner thigh had decreased to "...mid inner thigh approx.(approximately) 5 cm" and the reddened area to the foot had "...decreased as well." No further treatment was ordered by the physician other than to "Observe". Review of Resident 28's Progress Notes revealed no evidence to indicate the burn injury was monitored and treated until 11/23/14 at 2:37 AM (over 24 hours later). Documentation stated "...Blistering showing in leg burn yesterday that occurred during supper time. [MEDICATION NAME] applied". The location of the blistered skin areas of the leg were not identified and measured. There was no evidence to indicate assessment and monitoring of the burn until 11/24/14. Review of Resident 28's Progress Notes dated 11/24/14 at 2:52 AM documented "...burn to left inner thigh, blister the size of quarter has popped and skin is very red, superficial, open wound noted. Area around wound is red, area to left inner knee red, and left foot is red. When asked what happened to resident, aide tells this nurse that resident spilled coffee on (self) on 11/21/14". Documentation indicated a plan to notify the physician for orders for ointment or some type of dressing. On 11/24/14 at 1:30 PM, Nursing Assistant (NA)-B was observed assisting Resident 28 out of bed. The resident had an open skin area on the left inner thigh from a blister that had popped. The area was not measured at that time but the approximate size was larger than a 50 cent piece. During interview on 11/25/14 at 10:40 AM, the Director of Nursing (DON) verified Resident 28's left inner thigh wound had not been measured. The DON indicated the physician was notified for treatment orders on 11/24/14 and the physician ordered application of [MEDICATION NAME] to the wound 2 times daily. Review of a Weekly Wound Record initiated 11/25/14 revealed Resident 28 had a wound on the left inner thigh that measured 3.8 cm x 4.7 cm on 11/25/14. On 11/30/14 the wound measured 3 cm x 3.8 cm. D. Review of Resident 35's MDS dated [DATE] revealed the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The same MDS indicated the resident had moisture associated skin damage. Review of Transfer and Referral Record from the hospital dated 9/17/14 revealed Resident 35's coccyx was slightly reddened. Review of Resident 35's Progress Notes dated 9/17/14 at 4:02 PM revealed the resident's skin was described as "....warm dry and intact". There was no evidence to indicate the resident's coccyx or buttock area was reddened. Review of Admission and Weekly Skin Integrity Action Tool dated 9/24/14 revealed no evidence to indicate Resident 35 had a skin integrity problem. Review of Admission and Weekly Skin Integrity Action Tool dated 10/6/14 and 10/13/14 revealed Resident 35's buttocks were reddened and [MEDICATION NAME] (topical medication containing menthol and zinc oxide which protects skin from moisture and minor irritation) cream was applied after incontinent brief changes. There was no further assessment regarding the resident's reddened buttocks area. Review of Physician Orders dated 10/16/14 revealed orders for [MEDICATION NAME] (topical medication used to treat minor skin irritation by forming a barrier on the skin to protect it from irritants/moisture) cream as needed and [MEDICATION NAME] cream as needed. Review of Resident 35's Medication Flowsheet dated 10/2014 revealed an order for [REDACTED]. Review of the Admission and Weekly Skin Integrity Action Tool dated 10/20/14 revealed Resident 35's buttocks were red and [MEDICATION NAME] was used with incontinent brief changes. There was no documentation on the Admission and Weekly Skin Integrity Action Tool dated 10/27/14 regarding Resident 35's skin condition. Review of the Admission and Weekly Skin Integrity Action Tool dated 11/3/14, 11/10/14 and 11/17/14 revealed no assessment or documentation regarding Resident 35's reddened buttocks area. Review of progress notes dated 11/19/14 at 7:15 PM indicated the resident was seen by the physician due to possible yeast infection beneath the resident's breasts and lower abdominal folds and "...Do show MD residents bottom". There was no assessment or documentation regarding the skin condition on the resident's buttocks/coccyx area. Review of Resident 35's Medication Flowsheet dated 11/1/14 through 11/24/14 revealed no evidence to indicate [MEDICATION NAME] or [MEDICATION NAME] creams had been used. Review of the Admission and Weekly Skin Integrity Action Tool dated 11/24/14 revealed no assessment or documentation regarding Resident 35's buttocks area. Nursing Assistants A and E were observed to provide Resident 35's perineal hygiene on 11/25/14 at 7:35 AM. The skin on the resident's buttocks, coccyx and rectal areas was red and excoriated. Nursing Assistant (NA)-E stated the reddened excoriated areas had "gotten better then gets worse again" and "it comes and goes". NA-A and NA-E indicated [MEDICATION NAME] (topical cream containing menthol and zinc oxide) was applied each time incontinent care was provided. |
2015-07-01 |