| 12426 |
GOOD SHEPHERD LUTHERAN HOME |
285148 |
2242 WRIGHT STREET |
BLAIR |
NE |
68008 |
2010-06-10 |
314 |
G |
0 |
1 |
P9FH11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference: 175 NAC 12-006.09D2a and 12-006.09D2b Based on observation, interview, and record review, the facility failed to assess skin breakdown and follow facility skin policy for 1 (Resident 6) and evaluate causal factors and implement additional interventions to prevent pressure sores from developing for 1 (Resident 1) of 16 sampled and 10 non-sampled residents. The facility had a total census of 80. Findings are: A. Resident 6 was admitted to the facility on [DATE] according to admission and discharge summary. The admission and discharge summary listed the following [DIAGNOSES REDACTED]. A review of Resident 6's quarterly MDS (Minimum Data Set; a comprehensive assessment used for care planning) dated 6/7/10 listed Resident 6 as requiring extensive assistance of one for bed mobility and limited assist of one for transfer, toilet use, walk in room, and personal hygiene. Resident 6 was listed as having an OK short and long term memory and being independent with cognitive skills for daily decision making. A review of Resident 6's Care Plan revealed a problem dated 3/8/10 of potential for altered skin integrity with the following interventions: - " [MEDICATION NAME] paste/moisture barrier cream to peri/rectal areas prn (as needed) redness " - " Res (Resident) sleeps on pressure relief mattress " - " Encourage Res to use commode, may use bed pan for no longer than 5 minutes " - " Encourage Res to roll over and transfer weight " A review of Skin Charting Notes dated 2/16/10 revealed Resident 6's open area to left buttock was healed. On a 4/30/10 Braden Scale (a tool used to predict pressure sore risk), Resident 6 scored 22. A Braden Scale score of 9 or below was considered severe risk, 10-12 high risk, 13-14 moderate risk, and 15-18 mild risk for development of pressure sores. In interviews between 2:20-2:50 PM and at 4:50 PM on 6/8/10, Resident 6 reported Resident 6 had a " bed sore " on Resident 6's bottom. Resident 6 estimated Resident 6 had the pressure sore for 2 weeks and had been putting creme on it that was provided by a facility staff member. Resident 6 had creme that Resident 6 was using on pressure sore in Resident 6's drawer in room. A review of Resident 6's medical record on 6/8/10 did not reveal any documentation regarding a pressure sore on Resident 6's bottom. Observations at 3:20 PM on 6/8/10 revealed an open area with surrounding red tissue on Resident 6 ' s left buttock. Nurse's Notes dated 6/9/10 at 10:30 AM stated " .5 cm (centimeter) round superficial open area noted while bath was being given " . Wound assessment and Care Tool with Braden Scale for Resident 6 dated 6/9/10 stated Resident 6 had a .5 cm x .5 cm x .2 cm, Stage II pressure sore on left buttock. Pressure sore was being treated with moisture barrier cream. Observations on 6/8/10 at 7:45 AM, 8:30 AM, 10:05 AM, 11:30 AM and 5:16 PM and on 6/9/10 at 8:30 AM, 9:46 AM, and 11:55 AM, revealed Resident 6 resting in bed on back with head of bed elevated. In an interview on 6/8/10 at 4:20 PM, the DON (Director of Nursing) reported Resident 6 had a standard pressure relieving mattress on bed. A review of physician's orders [REDACTED]. In an interview on 6/9/10 at 2:35 PM, the DON reported the physician order [REDACTED]. In an interview on 6/9/10 at 10:17 AM, Nurse Aide B reported assisting Resident 6 to clean up the previous week. Nurse Aide B reported Resident 6's bottom was red and Nurse Aide B notified the charge nurse who provided Resident 6 with creme to put on bottom. In an interview on 6/10/10 between 10:33-10:45, Wound Nurse LPN (Licensed Practical Nurse) C reported Wound Nurse LPN C had not become aware of Resident 6's pressure sore until 6/9/10 nor was Wound Nurse LPN C aware Resident 6 was putting creme on it. Wound Nurse LPN C reported Wound Nurse LPN C was to be notified of all pressure sores including stage I pressure sores. A review of facility treatment checklist updated 9/09 for Stage II pressure sores revealed the following steps are to be taken in addition to others: -Measure and record in skin notes, -Relieve pressure. -Review standing orders-Wash with Wound Cleanser, Pat dry, Apply Skin Prep to peri-wound skin allow to dry 1 min., Apply Exuderm to area change every 3 days and PRN (as needed) until healed -Request RD (Registered Dietitian) consult -Initiate repositioning every 2 hours, if not being done-maximum up 2 hours if coccyx or Ischial area -Complete Unusual Occurrence Report and Investigation; Notify MD (Physician), DON, Skin nurse, family, therapies B. Record review of an Admission and Discharge Summary sheet dated 11/16/2009 revealed Resident 1 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Record review of Resident 1's significant change in condition dated and signed as completed on 4/01/2010 revealed the staff assessed the following about the resident: -Short and long term memory problems. -Modified independence in daily decision making. -At ease doing planned or structured activities. -Extensive assistance with toilet use. -total dependence with bed mobility, transfers, locomotion, eating and personal hygiene. -Decline in function. -Frequently incontinent of bowel and bladder. -Weight loss. -1 Stage II pressure ulcer ( the ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater). Review of Resident 1's Nurses Notes (skin) dated 2/23/2010 revealed Resident 1 was assessed to have an open area to the coccyx area that measure 3cm x's 2.5cm x's 0.1cm. Record review of a Wound Care Doctor Fax dated 2/23/2010 revealed the area to the coccyx was assessed as a Stage II pressure area. Record review of Resident 1's record did not contain an assessment of casual factors in an attempt to determine the reason why Resident 1 had developed a pressure ulcer after being assessed at low risk for pressure ulcers. According to a Wound Assessment and Care Tool with Braden Scale sheet dated 3/26/2010, the area to Resident 1's coccyx had healed. Record review of a Skin Nurse's notes dated 4/19/2010 revealed that Resident 1 had developed a "split at the coccyx area". Record review of Resident 1's record did not contain an assessment of causal factor or if the "split" was caused from pressure. The record did not contain Wound Assessment sheets for monitoring of the "split" to the coccyx. Record review of Resident 1's Nurse's Notes dated 6/05/2010 revealed the resident had developed an open area to the right buttock. The resident's record did not contain evidence of causal factors for the development of the area and to rule out pressure as a cause of the open area. Record review of a Fax communication /Facility Request sheet dated 6/09/2010 revealed the resident physician had been notified of the area 4 days after the facility had identified the open area. Observation on 6/08/2010 at 7:40 AM revealed Resident 1 was seated in a dinning room chair with out any pressure reliving/reducing cushion in the chair. Observation on 6/09/2010 at 8:00 AM revealed that Resident 1 was in the dinning room for breakfast. Resident 1 was seated in a dinning room chair and did not have a pressure reducing/reliving cushion in the chair. Record review of Resident 1's Comprehensive Care Plan (CCP) dated 4/05/2010 did not identify that Resident 1 had a history of [REDACTED]. An interview with LPN C was conducted on 6/09/2010 at 8:59 AM. During the interview LPN C confirmed that (gender) was the wound treatment nurse. When asked if the causal factors had been assessed in an attempt to determine why Resident 1 developed a pressure ulcer, LPN C state"no, (gender) had a decline, but I'm not sure". An interview with the DON was conducted on 6/09/2010 at 3:50 PM. During the interview, the DON was asked if Resident 1 needed to have a cushion in the dinning room chair, the DON stated "yes". Record review of an undated Policy and Procedure for Pressure Sore provided by LPN C revealed the following: -#7, Routine preventive care measures provided to prevent pressure sores will include; turning and proper positioning, application of pressure reduction or relief devices.... -#13, If a resident does develop a pressure sore, documentation in the record will support based on the condition of the resident, the pressure sore was clinically difficult to prevent. -#14, Any resident with a pressure sore will receive the necessary treatment and services to promote healing, prevent infection and prevent new sores from developing. The following measures will be implemented and documented on the comprehensive care plan and medical record, relieving pressure... |
2014-07-01 |