| 12667 |
MATNEY'S COLONIAL MANOR |
285082 |
3200 G STREET |
SOUTH SIOUX CITY |
NE |
68776 |
2011-01-27 |
280 |
D |
|
|
HE0G11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D7 Based on observation, record review and staff interviews; the facility failed to revise the care plan problems and interventions to promote skin healing for Resident 1. The survey consisted of 6 sampled residents from a facility census of 52. Findings are: Resident 1 was admitted to the facility on [DATE] according to Resident 1's medical record face sheet. Medical [DIAGNOSES REDACTED]. Record review of Resident 1's Minimum Data Set (MDS: A federally mandated comprehensive assessment tool used for care planning), Medicare readmission/return assessment dated and signed as completed on 11-10-2010, revealed that the resident was assessed with [REDACTED]. -Resident 1 received a score of 4 out of a total score of 15 on the BIMS (Brief Interview for Mental Status), - Resident 1 received a score of 2 in Section C1300, for the areas of Inattention and Disorganized Thinking, indicating the " Behavior present, fluctuates (comes and goes, changes in severity), however, this was not a change from resident's baseline, - Resident 1 used a wheelchair for mobility, - Resident 1 was documented as "Frequently incontinent" of urine and "Occasionally incontinent" of bowel (Section H), - Resident 1 was recorded in Section K for height of 60 inches and weight of 186 pounds, - Resident 1 was considered a risk of developing pressure ulcers under Section M0150, - Resident 1 had "2" Stage 2 ulcers (Section M0300). Review of Resident 1's Wound/Skin Records revealed that Resident 1 had [MEDICAL CONDITION] cm Site B wound, marked as "Healed" on 10-27-10 pictured to be on the left posterior leg/lower buttock, on the inner and upper aspect near the perineal region. Subsequent weekly documentation for Site B included: - 11-5-10; 1 x 1cm. No exudates. Intervention requested (see orders below) - 11-10-10; 4 x 1.5cm. No exudate. - 11-17-10; 4 x 1.5cm. Sanguinous exudate (bloody drainage). - 11-24-10; 3.2 x 1.2cm. With serosang drainage (watery (serum)bloody drainage). - 12-1-10; 3 x 1.4cm. Serosanguinous drainage. - 12-8-10; 2.8 x 1.3cm. Serous. (serosanguinous?). - 12-14-10; 2 x 1cm. Serous drainage. - 12-21-10; 4 x 2.7cm. Serosanguinous drainage. - 12-22-10; 2 x .3cm. Sanguinous drainage. - 12-28-10; 2.5 x 2cm. Serosanguinous drainage -Intervention requested (see orders below). - 12-28-10; 2 x .1cm. Scabbed; Note same date with 2 different measurements. - 1-5-11; Healed. - 1-5-11; 2 x 2cm. Serosanguinous drainage. Note same date with 2 different measurements/conditions - Intervention requested on 1-9-11 (see orders below). - 1-12-11; 6 x 4cm. Serous yellow tinged drainage. Intervention requested on 1-13-11 (see orders below). - 1-19-11; 5.5 x 3.2cm. Serous yellow tinged drainage (Resident first seen by wound clinic on 1-18-11). - 1-26-11; 6 x 3cm. Serous yellow tinged drainage. Review of Resident 1's medical record revealed fax copy requests to Resident 1's physician requesting the following: - 11-5-10 " Res (resident) rt (right) buttocks et (and) lt (left) posterior thigh is open. May we have the following tx. Cleanse with dermal wound apply stoma powder et calmoceptine to areas q (every) shift et PRN (as needed). D/c (Discharge or stop) when healed. " The physician indicated " Yes. " - 12-28-10 " May we d/c tx (treatment) to left lower buttock et upper posterior thigh et change tx to: Cleanse area with dermal wound cleanser, sprinkle open area with stoma adhesive powder, apply [MEDICATION NAME] mixed with stoma adhesive powder to area do Q shift et PRN. D/C when needed. " The physician indicated "Yes." - 1-9-11 Review of Resident 1's nursing notes revealed " Fax sent for change in tx to lower buttock et upper thigh (post) ( posterior) . Res incont (incontinent) more frequently of bladder area has deteriorated, darker hues of purple present, moist, shiny, areas tx had been previously (calmo/soma see MAR) (Medication Administration Record) changed to from [MEDICATION NAME] et duorderm req. change d/t (due to) duoderm was pulling on new skin growth when removed, et would get saturated (Incont (incontinent) of B & B (bowel and bladder) (at times) tx not changed daily only Q3 days, fax sent for tx of [MEDICATION NAME] with 4X4 to be changed BID (twice daily) to attempt to help heal area." Signed by LPN A. - 1-13-11 "May we have a order to send resident to ET nurse regarding areas to left lower buttocks et upper thigh. Have changed tx X (times) 3 and not much improvement." The physician indicated "Yes." Review of Resident 1's medical record revealed a Norton Plus Pressure Ulcer Scale assessment completed on 10-10-10 totaling a score of "7." The record stated a " Score 10 or less = High Risk)." Review of Resident 1's medical record revealed a care plan [DIAGNOSES REDACTED]. The short term goal of this care plan was: "Area to buttock will remain healed." Care plan interventions/approaches for "Risk for Pressure Ulcers/Alteration in skin" include: - Monitor skin with cares - Assist and ensure with repo (repositioning) at least ac, pc, and hs, plus every two hours in night (ac = before meals, pc = after meals, hs = hour of sleep or bedtime) - Norton scale quarterly - Notify doctor of red or open areas - Use of pressure reduction mattress and w/c (wheelchair) cushion roho - Tx (treatment) per MAR (Medication Administration Record) - Monitor for red or irritated areas on buttocks/abd (abdomen) folds, assist with hygiene-may use PRN (as needed) [MEDICATION NAME] and/or [MEDICATION NAME] - Clean lt (left) hand at least daily, apply cream per MAR - Use stand up lift for all transfers, do not pivot - Treatment to buttocks per order Review of the facility's Pressure Ulcer Documentation Protocol , Nursing Responsibilities, Director of Nursing/Designee states on page 11, number 20, "Care plan to identify potential and/or actual skin breakdown. Identify risk factors and preventative measure and pressure relief measures." Interview with the DON (Director of Nursing) on 1-27-11 at 12:50PM discussed Resident 1's care plan. When the DON was asked if the care plan reflected each of the incidents of skin breakdown for Resident 1 and treatment changes which had taken place, the DON stated, "No." Interview with the DON on 1-27-11 at 12:50PM discussed Resident 1's actual skin breakdown, as documented on the Weekly Wound/Skin Record. The DON confirmed that the breakdown was a "pressure sore," and that the nursing [DIAGNOSES REDACTED]. The DON confirmed that "[MEDICATION NAME] changes were made but were not documented on the care plan." |
2014-04-01 |