| 12166 |
SUTTON COMMUNITY HOME, INC. |
285277 |
1106 NORTH SAUNDERS |
SUTTON |
NE |
68979 |
2011-06-09 |
323 |
L |
1 |
1 |
3HMU11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09D7b Based on observation, record review and interview; the facility failed to protect one (Resident 7) from injury of burn from a heat blanket. This had the potential to affect all 30 residents due to all residents have the order for heat packs as desired for generalized discomfort. The facility census was 30 with a sample size of 27 residents. Findings are: Observation of Resident 7 at 3:05 PM on 5/31/11 revealed this resident in the dining room in motorized wheelchair waiting for nails to be polished. This resident had glasses on and was dressed in a blouse and shorts. Had ankle socks on with legs supported by bilateral wheelchair leg supports. Left lower leg wrapped with with clean, dry dressing. Interview of the Resident 7 at 4:30 PM on 5/31/11 revealed that this resident stated, "No" when asked if had pain at this time. Resident was up in motorized wheelchair in dining room watching birds in aviary. Resident pointed to left lower leg dressing and stated, "It feels better now." Resident had slow, garbled speech and was asked to repeat "It feels better now" for proper understanding. Record Review on 5/31/11 of the Physician order [REDACTED]. --original order date of 9/28/10 was for the Heat Packs BID (two times a day) and PRN (when required). May use heat packs one hour after Ketoprofen (Topical medication used for pain on left knee, lower back, left shoulder, and right forearm); --[DIAGNOSES REDACTED]. --another order with original order date of 3/2/11 was for the Heat Pack to the left hand PRN for 30 minutes for comfort and keep a minimum of 30 minutes between the applications; --Heat Pack treatment for [REDACTED]. --No order for lavender spa heat blanket. Record Review on 5/31/11 of Resident 7's MDS (Minimum Data Set federally mandated comprehensive assessment tool used for care planning, version 3.0) dated 4/11/11 revealed: --type of assessment was Annual Assessment; --sometimes makes self understood with the ability limited to making concrete requests; --understands others with clear comprehension; --summary score for repetition of three words, temporal orientation, and recall was 13 total out of 15 questions; --bed mobility was rated at the need for total dependence with assistance of two staff members for the moving to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture; --transfers was rated at the need for total dependence with assistance of two staff members for the Resident 7 to be moved between surfaces including to and from: bed, chair, and wheelchair; --mobility device that was used was the wheelchair; --[DIAGNOSES REDACTED]. --pain management in the last five days stated that Resident 7 had been on a scheduled pain medication regimen, received PRN medication, and had received non-medication intervention for the pain; --pain assessment interview was done with the Resident 7 and Resident 7 had frequent pain or hurting at anytime in the last 5 days and the pain did not affect this resident on the ability to sleep at night and did not cause this resident to limit day-to-day activities because of the pain; --pain intensity was rated by this resident at a numeric scale of 5 with moderate intensity. Record Review on 5/31/11 of the Resident 7's Plan of Care updated on 4/28/11 revealed: A) --a goal of Resident 7 will have no complaints of pain by the next review with the following approaches: 1. Offer massage to me when I am uncomfortable. Typically I like the same person to give my massage when I want it. I become "uncomfortable" when unfamiliar staff give my massage. 2. When I have pain, I am able to point to the appropriate Wong-Baker face (a picture graphic face for rating pain scale); --no further approaches or revision were stated in Resident 7's Plan of Care for use of pain approaches involving medication, non-medication or treatments. B) --a goal of Resident 7 to be able to maintain the ability to independently reposition self while in the bed during the night by next review with the following approaches: 1. When assisted to bed at night, position me on my stomach at the foot of the bed. 2. Attach my call light to my bedding with the attached clip. 3. Ensure that my back side rail is padded and in up position. 4. Use a contour mattress on my bed as a boundary marker. 5. Use the Hoyer lift with two assist for transfers. 6. One person total assist with personal hygiene. 7. One to two person total assist with dressing. 8. I am independent with locomotion throughout the facility in my motorized wheelchair with set up help only. 9. Ensure my safety belt is fastened on my motorized wheelchair, commode, and the foot pedal per my request and my Guardian's order. 10. Place a small pillow under my left armpit and slightly behind per my request and Guardian's request. 11. Place a gel cushion under my contracted toes and feet when in the bed. 12. Encourage me to report any mouth sores or mouth pain and report this to the charge nurse; Record Review on 5/31/11 of Resident 7's Treatment Sheets revealed: A) Heat packs BID and PRN for back pain with Reheater pack to back before arising and at HS (Given after 7 PM) and also PRN. May use heat packs one hour after Ketoprofen for [DIAGNOSES REDACTED]. --hours stated on the treatment sheet for May 2011 were PM (afternoon after 4 PM), NOC (night), and PRN; --no PM heat pack treatments were initialed by nursing staff for the months of May 2011 or March 2011; --one time on April 20th 2011, the PM heat pack treatment was recorded as given for this April 2011; --NOC for the heat pack treatment sheet for March 2011 were initialed as given, except on March 18th, March 20th, and March 24th; --NOC for the heat pack treatment sheet for April 2011 were initialed as given; --NOC for the heat pack treatment sheet for May 2011 were initialed as given, except on May 25th, May 26th, May 29th, and May 30th; B) Heat pack to the left hand PRN for 30 minutes for comfort and keep a inhuming of 30 minutes between applications for treatment of [REDACTED]. --the recorded PRN treatment was recorded as start date of 3/2/2011 with no record of receiving any in the month of March 2011 --received one time for this PRN treatment on April 18th, 2011; --no PRN treatment received for May 2011. Observation (Copies obtained) of Heat Packs (TheraBeads) on 5/31/11 that were used on Resident 7 revealed: --Heat Packs were titled TheraBeads which were in a standard pack of 12"x12"; --Instruction on the TheraBead heat pack stated "When using a Therabead Heating Unit Press code 1," and "When using a conventional microwave unit heat to approximately 2 minutes, refolding and rotating in the oven after half the indicated time increment in 30 second intervals until the skin temperature monitor indicates Therapeutic Range." --the skin temperature monitor is on the heat packs and indicated "Correlated Skin Temperature Therapy Range." On the one end of the temperature monitor is the word of "re-heat" with the Celsius of 40 degrees to 45 degrees and on the right of this is the word "Do not apply." --the heat packs are put into a terry cloth cover before being put on the resident. --4 out of 6 of these heat packs had multiple dark brown areas on each side of them and 3 out of 6 of these had skin temperature monitors that were cracked and peeling; --4 out of the 6 of these heat packs had edges that were frayed. Observation of the Heat Blanket (TheraBeads) on 5/31/11 that was used on Resident 7 revealed: --Heat Blanket was titled TheraBeads and was a Lavender Spa blanket with size of 18"x44" --this heat blanket did not have a skin temperature monitor on it for indicating heating range; --heat blanket had a terry cloth cover to put it before contact with the resident; --microwave instructions on this Heat Blanket stated, "Warning!" Microwaves vary in power. Start at 30 seconds full power. Add time in 10 second increments until desired temperature is reached. "Do Not Overheat To Avoid Risk Of Fire." --WARNING: FOLLOW INSTRUCTIONS TO AVOID INJURY: Cleanse treatment area from body lotions, oils or gels prior to the application of the pad. Contact with lotions, oils or gels can alter the effectiveness of the TheraBeads. Interview with Director of Nursing, Administrator, and Assistant Director of Nursing at 5:25 PM on 5/31/11 revealed: A) The incident was discovered in the morning of 5/28/11 by the NA (Nurse Aide) 1 when Resident 7 was up on the commode and pointed to a red area on left lower leg. NA 1 alerted LPN (Licensed Practical Nurse) 3 and this nurse assessed the wound which at that time was a blister on the left lower leg and notified the Administrator and physician on call. New order from the physician was obtained for the burn and covered. A message was left for the guardian of Resident 7 initially via voice mail but not recorded by the Administrator. The order for the heat pack was to be done BID (twice daily) and PRN (when necessary). The heat packs were stored in the treatment room and warmed up in the microwave and covered with the terry clothes. The heat blanket (Lavender Spa blanket) was stored in Resident 7's room and heated up in the microwave in the treatment room then it was brought back into Resident 7's room with a terry cloth cover on it. There were no orders from the physician on using the heat blanket (Lavender Spa Blanket) and no temperature to heat this too. There was a therapy range for heat indicator on the heat packs, but no heat indicator on the heat blanket. The heat blanket was brought in because of its larger size of 18x44" to cover resident 7's shoulders to lower back when in bed. The treatment times were in the PM (evening) and NOC (early morning around 5 or 6 AM). B) Interview with the Administrator revealed that this person had brought in the Sonoma Lavender Spa Blanket. No order was obtained for use of this blanket. There was no policy and procedure on the use of the heat blanket. C) Interview with the DON and ADON revealed that there was no policy or procedure on the heat blanket and the only guideline on the heat packs was posted in the treatment room on the bulletin board and stated: "Heat Pack Guidelines." 1) Check list of residents for skin sensitivity. 2) Heat ALL heat packs for 1 minute on high. DO NOT EXCEED 1 MINUTE. 3) Check heat pack for hot spots. Twist and roll to distribute heat evenly. Test temperature on bare skin of the employee's arm. 4) Wrap in Terry cloth cover. 5) Chart date, time, heat pack number and initials on clipboard sheet by microwave. 6) Apply heat pack to resident for 15-20 minutes at a time. Keep a minimum of two hours between applications to the resident. Chart time, initial and put results on Treatment Medex for each resident and application. 8) Information: a) Heat packs can only be used four (4) times in any 24 hour period. Please check the heat pack number to see what times it was last used, must keep six (6) hours of rest time between the use of the heat pack. --there were no other policies or procedures on the heat blanket or heat packs as of the date 5/27/11. Interview with Staff Development LPN on 5/31/11 revealed: --no inservices were done on policy and procedure for the use of the heat blanket or the heat packs; --following the burn to Resident 7 a "Heat or Cold Pack Therapy Policy Statement," was done with a note for staff to read and initial the policy with no one-on-one inservices for the staff to check competency; --as of the date of 5/31/11 only four staff had signed the policy statement indicating they read and understood the policy. Observation of Resident 7's left lower leg burn treatment at 8:10 AM on 6/1/11 revealed: --LPN 1 in room with Resident 7 up in motorized wheelchair for dressing change to left lower leg; --non-adherent gauze dressing removed with wound cleaned with sterile water and approximately 3 x 2 cm circular wound with no drainage but this wound did have redness around total circumference; --treatment of [REDACTED]. --Resident 7 complained of discomfort with cleaning of wound; --Resident 7 was watching television in room during treatment. Interview with LPN 1 at 9:00 AM on 6/1/11 revealed that there was no redness yesterday, but the blister on the left lower leg was raised up with fluid in it. Resident 7 was seen by the physician on 5/31/11. Observation of Resident 7 at 8:32 AM on 6/1/11 ; revealed this resident up in motorized wheelchair with a tray on it with food and drink on table eating and drinking without difficulty. Had glasses on and was dressed in a blouse and shorts. Wearing ankle socks. Had intact, clean dressing on left lower leg. Pillow behind left lower shoulder for positioning. Interview with the Administrator at 11:10 AM on 6/2/11 revealed: --the incident with Resident 7 getting a burn on 5/28/11 resulted in an investigation when called by the charge nurse LPN 3 at 7:39 AM; --incident report was filled out and the Administrator came into the facility to look at the burn and investigate what had happened; --the family (guardian) was called and a message was left due to no answer; --the heat blanket had caused the burn and not the heat packs. Interview with the ADON at 11:30 AM on 6/2/11 revealed that Resident 7 had not had the Care Plan updated under the pain management approaches since the date of 5/4/2010 and it is the responsibility of all professional nursing staff to updated the resident care plans. The resident care plans are kept at the nurses station. This violation was abated at the time of survey and the scope & severity was lowered to a 'F'. The facility put the following action into place: -All thermal packs were disposed of. -All heat therapy was suspended. -All current RNs and LPNs were trained by the Nurse Consultant. -All residents' physicians were notified of new procedures and the need for specific instructions and the use of warm compresses for each resident. |
2014-10-01 |