| 2869 |
KEYSTONE RIDGE POST ACUTE NURSING AND REHAB |
285238 |
7501 KEYSTONE DRIVE |
OMAHA |
NE |
68134 |
2018-01-02 |
686 |
H |
1 |
1 |
51KH11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER: 175 NAC 12-006.09D2a Based on observation, record review and interview; the facility staff failed to identify pressure ulcers and failed to implement assessed interventions to prevent development of pressure ulcers for 4(Resident 3, 36, 51 and 160) of 4 sampled residents. The facility staff identified a census of 66. Findings are: [NAME] Record review of Resident 51's Minimal Data Set (MDS: a federally mandated comprehensive assessment tool used for care planning) signed as completed on 12-06-2017 revealed the facility staff assessed the following about Resident 51: -Brief Interview for Mental Status (BIMS) was a 14. According to the MDS Manuel a score of 13 to 15 indicates a person is cognitively intact. -Required supervision with eating. -Required extensive assistance with 2 or more persons assisting with bed mobility, transfers, dressing, toilet use and personal hygiene. -Always incontinent of bowel and bladder. -Identified Resident 51 at risk for the development of pressure ulcers. Record review of Resident 51's Braden Scale (tool used for predicting pressure sore risk) dated 12-06-2017 revealed Resident 51 scored a High Risk rating. Record review of Resident 51's Comprehensive Care Plan (CCP) dated 11-24-2017 revealed Resident 51 had the [DIAGNOSES REDACTED]. Further review of Resident 51's CCP updated on 12-06-2017 revealed Resident 51 had returned from the hospital with an open wound to the sacrum and prevalon boots (type of pressure relieving foot wear) in place to both feet. According to Resident 51's CCP, the prevalon boots were worn at all times. Observation on 12-20-2017 at 2:49 PM revealed Resident 51 was in bed, in a back laying position and did not have the prevalon boots on. Observation on 12-21-2017 at 11:00 AM revealed Resident 51 was in bed, in a back laying position and did not have the prevalon boots on. Observation on 12-21-2017 11:22 AM revealed Resident 51 was in bed, in a back laying position and did not have the prevalon boots on. Observation on 12-21-2017 at 1:10 PM revealed Resident 51 was in bed, in a back laying position and did not have the prevalon boots on. Further observation on 12-21-2017 at 1:10 PM revealed Resident 51's Family member was in the room with Resident 51. Resident 51's Family member stated see (gender) doesn't have (gender) boots on and with a pointing movement indicated the prevalon boots were placed in a chair in Resident 51's room. Resident 51's family member confirmed the prevalon boots were to be on Resident 51. Observation on 12-21-2017 2:00 PM with Licensed Practical Nurse (LPN) B of Resident 51's heels revealed Resident 51 had an approximately 5 centimeters (cm) roundish fluid looking blister to the left heel. On 12-21-2017 at 2:00 PM an interview was conducted with LPN B. During the interview, LPN B confirmed Resident 51 did not have the prevalon boots on (gender) feet. LPN B further reported not being aware Resident 51 had a wound to the left heel. Record review of Resident 51's record revealed there was no evidence Resident 51 had a pressure area to the left heel. Further review of Resident 51's medical record revealed there was no evidence the facility had completed daily monitoring of Resident 51's feet. Record review of a Skin Pressure Ulcer Weekly (SPUW) sheet dated 12-21-2017 with a time of 2:50 PM revealed the area to Resident 51's left heel was measured as 2.9 cm by 2.5 cm and staged as a Suspected Deep Tissue Injury ( SDTI). The description of the left heel SDTI was identified as black/brown, eschar (dead tissue). According to Woundeducators.com, a SDTI is A deep tissue injury is a unique form of pressure ulcer. The National Pressure Ulcer Advisory Panel defines a deep tissue injury as A pressure-related injury to subcutaneous tissues under intact skin. Initially, these [MEDICAL CONDITION] have the appearance of a deep bruise. B. Record review of Resident 3's MDS dated as completed on 10-03-2017 revealed the facility staff assessed the following about the resident: -BIMS was a 15. -Total dependence for bed mobility, transfers, dressing, eating, toilet use and personal hygiene with 2 plus people assisting with bed mobility, transfers, dressing and personal hygiene. -No pressure ulcers were identified for Resident 3. Record review of a Skin Evaluation sheet dated 12-17-2017 revealed there were not any pressure ulcers identified for Resident 3. Record review of a Braden Scale evaluation sheet dated 9-21-2017 revealed Resident 3 was evaluated as low risk for the development of pressure ulcers. Record review of Resident 3's CCP dated 10-13-2017 revealed Resident 3 was to have Prafo (type of pressure relieving boots) while in bed. Further review of Resident 3's CCP dated 12-17-2017 revealed Resident 3 had the potential for impaired skin integrity and pressure. The goal for Resident 3 was to remain free of sign and symptoms of new skin breakdown. Interventions identified were to assist with repositioning, Prafo boots while in bed, pressure reducing mattress and wheelchair cushion. On 12-21-2017 at 4:12 PM an interview was conducted with Resident 3. During the interview Resident 3 reported having a pressure ulcer to the right heel. Review of Resident 3's medical record revealed there was no evidence the facility staff had identified a pressure ulcer on the resident's right heel. On 12-26-2017 at 5:04 AM an interview was conducted with Resident 3. Resident 3 reported (gender) had a pressure ulcer to the right heel. On 12-26-2017 at 5:20 AM observation of Resident 3's right heel with Registered Nurse (RN) D revealed a had a dark purple looking area to the right heel. Record review of a SPUW sheet dated 12-27-2017 revealed Resident 3 was identified with an unstageable pressure ulcer to the right heel that measured 1.5 cm by 4.0 cm. The wound bed was identified as black/brown eschar. On 12-27-2017 at 7:26 AM an interview was conducted with Registered Nurse (RN) E. During the interview RN [NAME] reported there was no monitoring of the right heel ulcer for Resident 3. C. Record review of Resident 160's MDS dated as completed on 12-20-2017 revealed the facility staff assessed the following about the resident: -BIMS was a 6. According to the MDS Manuel, a score of 0 to 7 indicates severe cognitive impairment. -Required extensive assistance with bed mobility, transfers, toilet use and personal hygiene. -Resident 160 was identified at risk for developing pressure ulcers. -No pressure ulcers were identified for this resident. Record review of a Braden Scale form dated 12-07-2017 revealed the facility assessed Resident 160 as a low risk for the development of pressure ulcers. Observation on 12-27-2017 at 6:30 AM revealed Resident 160 was in bed, in a back laying position. Observation on 12-27-2017 at 7:45 AM revealed Resident 160 was in bed, in a back laying position. Observation on 12-27-2017 at 8:25 AM revealed Resident 160 was in a back laying position. Observation on 12-27-2017 at 1:35 PM with RN [NAME] revealed Resident 160 had several red areas with defined edges. Record review of a SPUW sheet dated 12-27-2017 timed at 7:47 PM revealed the facility staff assessed Resident 160 with 3, stage 1 (Intact skin with a localized area of non-blanchable [DIAGNOSES REDACTED] (redness) caused from pressure) pressure ulcer. The 3 pressure ulcers were identified as the following: -Site 1, left buttocks, stage, with measurements of 2.0 cm by 0.6 cm. -Site 2, lower left buttocks, stage 1 with measurements of 2.0 cm by 0.6 cm. -Site 3, right buttocks, stage 1 with measurements of 2.0 by 1.0 cm. C. Review of Resident 36's Comprehensive Care Plan (CCP) revealed a problem statement of: Alteration in skin integrity. Resident 36 requires assistance with repositioning. The CCP revealed on12/13/17 Resident 36 was identified as having a pressure ulcer on the coccyx (tailbone). Review of Resident 36's Comprehensive Care Plan for Bed Mobility revealed Resident 36 required extensive assistance of 1 staff to reposition and turn in bed and staff to assist Resident 36 every 2 hours and as needed. 12/27/2017 observations of Resident 36 revealed the resident was in the following positions: -6:30 AM; On back. -7:00 AM; On back -7:50 AM; On back, -8:35 AM; On back, -9:15 AM; On back, -9:40 AM; On back. Observation on 12/27/2017 at 9:40 AM of Resident 36 revealed an area on Resident 36's coccyx bony prominence was open. Interview on 12/27/2017 at 9:40 AM with the Assistant Director of Nursing (ADON) revealed Resident 36 should have been turned at least every 2 hours. Review of a facility form dated 12/18/2017 revealed Resident 36 had a pressure ulcer on the resident's coccyx identified on 10/30/2017 as unstageable which was assessed as healed on 12/18/2017. Review of wound documentation dated 12/23/2017 revealed Resident 36 had no alteration of skin integrity. Review of the facility document dated 9/2017 titled Wound Management revealed the purpose of the policy was to ensure the resident did not develop pressure ulcers unless clinically unavoidable and the facility provided care and services to prevent the development of additional pressure ulcers. Interview on 12/27/2017 at 2:00 PM with LPN-C revealed Resident 36 did have an area on the coccyx that had previously healed and did reopen and is a stage 2 area with a small unstageable area in the center. |
2020-09-01 |