| 12653 |
HIGHLAND PARK CARE CENTER |
285063 |
P O BOX 950, 1633 SWEETWATER |
ALLIANCE |
NE |
69301 |
2011-04-11 |
314 |
G |
|
|
8W6H11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09D2a 175 NAC 12-006.09D2b Based on observations, record review, and staff interviews; the facility failed to provide interventions to prevent the development of pressure sores for a resident identified at risk for the development of pressure sores, failed to provide care including treatments as ordered by the physician, and failed to provide pressure relief to promote healing of a pressure sore for 1 sampled resident (Resident 67). The facility census was 45 and the Stage 2 survey sample size was 27 residents. Findings are: Review of the "Face Sheet" revealed that Resident 67 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the "Admission Nursing Evaluation", dated 1/13/11, revealed that the resident had no pressure ulcers, was lethargic, was confused at times, did not resist cares, and required assistance with 2 people for bed mobility, transfers, toileting, personal hygiene, and bathing. Review of the "Braden Scale - For Predicting Pressure Sore Risk", dated 1/13/11 revealed a score of "18" and on 1/20/11 a score of "14". According to the form, a score of "15-18" was mild risk and a score of "13-14" was moderate risk. Review of the "Interdisciplinary Progress Notes", dated 1/16/11, revealed that 2 areas were noted on the right buttock that were reddened area with superficial skin impairment. The right was circular with a diameter of 4 cm. (centimeters) and no bleeding. Left area measured 4.75 cm. x 4 cm. with loose skin covering the area which was reddened and irregular and with evidence of deep red areas underneath the loose impaired skin. "[MEDICATION NAME]" was applied. Review of the treatment record for January 2011 revealed an order, dated 1/16/11, to monitor pressure ulcer on left and right buttocks and apply "[MEDICATION NAME]" until resolved. Review of the "Pressure Ulcer Record", dated 1/17/11, revealed that the bath aide reported fluid filled blisters on the resident's right heel and left heel and heel floating boots were applied to the feet. Further review revealed no assessment of the blisters, including causal factors or further treatment interventions. The dietary department and the physician were notified of the blisters on 1/20/11. An assessment was completed on 1/21/11 for the left heel as follows: Stage - DTI (Deep Tissue Injury, suspected deep tissue injury, which presents as purple or maroon localized area of discolored intact skin or blood filled blister due to damage of underlying soft tissue from pressure and/or shoes, and the area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue). Size was 5 cm. X 5 cm., and depth unknown. There was no undermining or no exudate. Surrounding skin color was pink with no pain. Review of the assessment, dated 1/21/11, for the right heel revealed Stage - DTI, that was size 9 cm. X 12 cm. Depth was unknown. There was no undermining or exudate. Surrounding skin color was pink, and there was no pain. Review of the "Admission Nursing Evaluation", dated 2/2/11, revealed that the resident was readmitted to the facility after hospitalization for Pneumonia. Review of the skin condition section revealed that the resident had skin tears at the right arm, and dressings were dry and intact at both heels. Further review revealed no assessment of the heels. Review of the "Interdisciplinary Progress Notes", dated 2/2/11, revealed that the RN (Registered Nurse) would assess the heels and a small pressure area at the right buttocks. Review of the "Weekly Pressure Ulcer Record", dated 2/3/11, revealed the following for the left heel: unstageable, 3 cm. X 4 cm., no exudate, no odor, surrounding skin intact, surrounding tissue/wound edges, pink/smooth, and no pain. Review of the "Weekly Pressure Ulcer Record", dated 2/3/11, revealed the following for the right heel: unstageable, 7 cm. x 10.5 cm, depth - superficial, scant serosanguinous drainage, and no odor. Review of the current "Care Plan", goal date 5/19/11, revealed a problem pressure ulcers on both heels and history of a healed pressure ulcer on right buttock. Approaches included measure wounds weekly and document the status of the pressure areas, administer treatments as ordered by the physician, provide diet and supplements as ordered, pressure reducing devices to bed and chair. On 3/4/11, surgical consult for right heel debridement was added. Further review revealed that the use of pressure relieving boots and the therapeutic setting for the air mattress were not on the care plan to ensure the optimal therapeutic benefits of pressure relief. Review of the "Interdisciplinary Progress Notes", dated 3/4/11, by the wound consultant nurse revealed that the resident had an unstageable pressure ulcer at the right heel which encompassed the entirety of the heel. It was covered with eschar and loosened nonviable tissue. Pink granulation tissue showed through with necrotic tissue in the same area. There was a moderate amount of red and yellow serosanquinous drainage on the dressing which was changed yesterday. Further review revealed that the wound nurse suggested that the wound be surgically debrided, use dressing of "[MEDICATION NAME]" to minimize the chance of infection, and change the dressing daily to control drainage. Review of the "Treatment" sheet, dated April 2011, revealed an order dated 2/3/11 to clean eschar heels with warm water or normal saline, pat dry, apply "[MEDICATION NAME]" to areas then "Vasoline". Staff was to cover the right heel with foam dressing and change every day and as needed. The left heel was left open to air, and off loading boots were to be on at all times. Review of the "Report of Consultation", dated 3/23/11, revealed that the podiatrist debrided the right heel pressure ulcer. Observation on 4/6/11 at 3:00 PM revealed the resident seated in the wheelchair with foot rests in place, seat cushion in place, and protective boots on bilaterally. Interview with PTA (Physical Therapy Assistant) - G revealed that the left foot was healed and the nurses continued to treat the right heel. Further observation revealed that the resident had an air mattress set at "5 1/2" at normal pressure. The dial showed a rate of "1 - 10". Observation on 4/7/11 at 7:20 AM revealed the resident seated in the wheelchair in room with the right foot directly on a vinyl covered pad on the floor used as a calf support on the wheelchair. Further observation revealed that the resident moved the right foot up and rested it on a sock covered left foot. Reddish, brown malodorous drainage was noted on the sock and on the cushion. The DON (Director of Nursing) lifted the resident's right leg up for the treatment. RN (Registered Nurse) - B, set up supplies for the wound care, washed hands applied gloves, placed a towel on the floor over the vinyl cushion. RN - B proceeded to clean the wound with saline solution, patted the wound with a gauze pad, noted reddish brown colored drainage, and removed gloves. RN - B washed hands applied gloves, applied a skin prep to the surrounding skin, applied a "PolyMem" dressing, and secured the dressing with "[MEDICATION NAME]" tape. RN - B removed gloves and washed hands, returned to the resident and applied the protective boot to the right foot, removed the sock from the left foot, and noted a dry scaly area on the left heel. The DON stated that the nurses continued to use the protective boots for both feet to provide pressure relief for the heels. Interview on 4/7/11 at 1:40 PM with RN - B confirmed that the daily wound care consisted of cleaning the right heel wound with saline, applying skin prep to help the tape stay on the resident's skin, and the "PolyMem" dressing. RN - B did not mention the use of "[MEDICATION NAME]" or "Vaseline" as directed on the treatment orders. Interview on 4/7/11 at 2:00 PM with the DON confirmed that the nurses were to follow the dressing change procedure as ordered by the physician. Further interview confirmed that the resident's foot should have been positioned in a manner to provide pressure relief and comfort and to protect the pressure ulcer from direct contact with the vinyl cushion on the floor or the sock on the left foot to reduce the risk of infection. |
2014-04-01 |