| 848 |
MONUMENT REHABILITATION AND CARE CENTER |
285095 |
111 WEST 36TH STREET |
SCOTTSBLUFF |
NE |
69361 |
2019-05-28 |
686 |
G |
0 |
1 |
3V0011 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Numbers 175 NAC 12- D2 175 NAC 12-006.09D2b Based on observations, record reviews and interviews; the facility failed to provide care to prevent pressure ulcers and to promote healing, including repositioning at least every two hours, pressure relieving seat cushions, dressing changes as ordered, aseptic technique for dressing changes and follow up with ongoing resident non compliance with interventions for two current sampled residents (Residents 42 and 48). The facility census was 85 with 24 current sampled residents. Findings are: [NAME] Review of the Admission Record, printed 5/21/19, revealed that Resident 42 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Care Plan, goal date 6/18/19, revealed that the resident required assistance with activities of daily living including repositioning in bed, transfers and personal hygiene and cares. Further review revealed that the resident was at risk for pressure ulcers due to assistance required with bed mobility, diabetes, history of pressure ulcers and placed a pillow in the wheelchair. On 9/12/18, the resident had a pressure area to the coccyx and right buttock, on 1/17/19 the area to the coccyx was closed, on 2/22/19 the area was opened, and 5/17/19 the area was stable with 100% granulation tissue. Interventions included treatments as ordered, weekly skin assessments, pressure reducing wheelchair cushion and air mattress, the resident frequently sits on a pillow on top of the pressure reducing wheelchair cushion and staff will continue to educate the resident on the importance of not using a pillow on top of the pressure reducing device and to comply with treatment. Review of the Wound Evaluation Flow Sheet Multiple Weeks - V 4, dated 4/28/19, revealed the following including: - 2/22/19 Stage 4 pressure ulcer ( full thickness tissue loss with exposed bone, tendon or muscle, slough or eschar may be present on some parts of the wound bed, often include undermining and tunneling) at the coccyx which measured 0.5 cm. (centimeters) wide, 1 cm. long and 0.5 cm. depth; - pressure ulcer acquired in the facility; - tunneling/undermining at 0.5 cm.; - moderate amount of drainage present; - peri wound with macerated (moist)/soft skin; - treatment order 3/28/19 honey fiber and foam dressing and skin prep peri- wound; - current preventative interventions are pressure redistribution mattress and wheelchair cushion; - current wound status/additional comments included maceration peri-wound (around the wound) is worse, resident is non-compliant with utilizing pressure reducing wheelchair cushion appropriately and puts a pillow on top of the cushion, education provided on the risks associated with non-compliance. Further review revealed the Wound Evaluation Week 3 on 5/17/19 including: - wound measured 0.7 cm. long, 1 cm. wide (larger) and 0.5 cm. depth; - no drainage; - 100% granulation tissue; - 4/18/19 treatment order of honey fiber and foam dressing, change daily; - education provided on putting pillow on top of the pressure reducing wheelchair cushion; - maceration around the wound is resolved at this time. Observations on 5/20/19 at 9:44 AM revealed the resident seated in the wheelchair with a pillow placed on the top of the wheelchair cushion and the Microair mattress set at 8 which is for 315 pounds. Further observations at 2:50 PM revealed the resident resting on the bed, air mattress set at 8 and a pillow placed at the resident's lower back. LPN (Licensed Practical Nurse) - L, Charge Nurse, applied disposable gloves, assisted the resident to turn onto side, removed the dressing at the coccyx area, noted brown and red colored drainage on the dressing, noted open area approximately 2 cm. and 1 cm. in depth and surrounding skin reddened and macerated. LPN - L, wearing the same disposable gloves, cleansed the ulcer with saline, wiped the area with gauze, applied skin prep to the surrounding skin, changed gloves with no hand washing, applied the honey fiber dressing to the inside of the wound, resident stated that hurts and the cover foam dressing was applied. Review of the MAR (Medication Administration Record) for (MONTH) 2019 revealed an order, dated 3/21/19, for LiquaCal two times a day for wound healing. Further review revealed no documentation that the medication was administered on 5/2/19 at 5:00 PM or on 5/8/19 at 9:00 AM and 5:00 PM. Review of the TAR (Treatment Administration Record) for (MONTH) 2019 revealed an order to cleanse the wounds to the coccyx, pat dry, apply honey fiber to the wound bed, cover with foam dressing, change daily until resolved, apply skin prep around the wound to macerated skin, for Stage 4 pressure area. Further review revealed that the resident refused the treatment on 5/2/19 and no documentation that it was done on 5/7/19 and 5/10/19. Interview with the DON (Director of Nursing) on 5/21/19 at 3:50 PM confirmed that the air mattress was not set at a therapeutic level for the resident. The DON set the air mattress at 5 based on the resident's weight of approximately 200 pounds. Interview with the DON on 5/23/19 at 9:20 AM confirmed that the resident continued to sit in the wheelchair with a pillow over the pressure reducing cushion which decreased the therapeutic benefits of the cushion. Further interview confirmed that the resident should not place a pillow over the air mattress as that also reduced the effectiveness of the pressure relieving mattress. The DON confirmed that wound care needed to be done as ordered and the protein supplement needed to be administered as ordered to promote healing of the pressure ulcer. Further interview confirmed that dressing changes, including the proper use of disposable gloves and hand washing, should be done to promote healing of the pressure ulcer. The DON confirmed that the disposable gloves were to be removed after the soiled dressing was removed and hand washing done before new gloves were donned to treat and apply the clean dressing to reduce the risk of cross contamination. B. Review of Resident 48's Care Plan, goal date 7/2/19, revealed that the resident required assistance of two staff for bed mobility and transfers, had impaired cognition due to confusion and [DIAGNOSES REDACTED]. Interventions included weekly skin inspection, pressure reducing wheelchair cushion and mattress, reposition side to side during the night, educate the resident on the importance of off loading pressure and repositioning side to side to reduce the risk for pressure and to improve current skin issues, respect the resident's right to refuse, encourage the resident to lay down and reposition to sides between meal times and treatments as ordered. Review of the Weekly Skin Review - V 3, dated 5/16/19, revealed that the resident had an open area at the left buttock which measured 0.5 cm. by 0.5 cm. and an open area (not measured) at the right gluteal fold. Observations on 5/20/19 at 9:15 AM, 10:00 AM, 11:00 AM, 12:15 PM and 1:30 PM revealed the resident seated in the wheelchair with a pillow over the wheelchair seat cushion and the canvas mechanical lift transfer sling. Further observations at 1:30 PM revealed MA (Medication Aide - C and MA - D transferred the resident to the bed with a full mechanical lift. MA - C and MA - D removed the resident's soiled disposable brief and provided skin care. Dressings were noted on the resident's right and left inner buttocks areas. The resident was positioned on back after cares were completed and remained positioned on back at 2:30 PM. Interview with MA - D on 5/20/19 at 1:45 PM revealed that the resident usually sat in the wheelchair all morning, usually got up around 5:00 AM, and would sometimes agree to lay down in bed for awhile in the afternoon. so that the disposable brief could be changed. Further interview revealed that the resident could not reposition self in the wheelchair. Observations on 5/21/19 at 7:00 AM, 11:45 AM and 1:20 PM revealed the resident seated in the wheelchair with a pillow and mechanical lift sling over the wheelchair cushion. Observations on 5/22/19 at 5:00 AM, 7:50 AM, 9:00 AM, 12:00 PM, 1:30 PM and 3:10 PM revealed the resident seated in the wheelchair with a pillow and mechanical lift sling over the wheelchair cushion. Further observations at 3:10 PM revealed MA - N and MA - S transferred the resident from the wheelchair to the bed with the full mechanical lift for skin care. MA - N and MA - S removed the soiled disposable brief, noted smeary bowel movement and urinary incontinence and provided skin care. The resident's anal, coccyx and scrotum were noted to be excoriated with some open areas. Interviews with MA - N and MA - S on 5/22/19 at 3:10 PM confirmed that the resident had been in the wheelchair all day until now and was not able to reposition self in the wheelchair due to bilateral [MEDICAL CONDITION]. Further interview revealed that the resident often refused to lay down during the day to check and change the disposable brief, wanted the pillow and the lift sling kept in the wheelchair and didn't want to be repositioned in the wheelchair. Observations on 5/22/19 at 3:15 PM revealed RN (Registered Nurse) - M, applied disposable gloves, removed the dressing at the left inner buttock area and with the same gloves, cleaned the open area (which measured approximately 4 cm. x 1.5 cm.) with saline, applied skin prep around the wound and a collogen dressing and a cover dressing. RN - M removed gloves and applied new gloves without hand washing in between, repositioned the resident to the other side, removed the dressing at the right inner buttock, noted brown colored drainage on the dressing, cleaned the open area with saline (area measured approximately 4cm. x 1.5 cm.), applied skin prep to the surrounding skin and applied a collogen and cover dressings. RN - M applied [MEDICATION NAME] to open and excoriated areas at the anal, coccyx area and scrotum and assisted MA - N to apply a disposable brief. RN - N removed the disposable gloves and gathered trash and supplies. Further observations revealed that the resident requested to get up into the wheelchair and MA - N and MA - S transferred the resident back into the wheelchair with a pillow and the mechanical lift sling on top of the wheelchair seat cushion. Review of the Treatment Administration Record, dated (MONTH) 2019, revealed an order dated 5/10/19 for Collagen and foam to left buttock three times a day until healed. Further review revealed no documentation that the treatment was done at 10:00 PM on 5/13/19, 6:00 AM on 5/14/19 and at 2:00 PM on 5/17/19. Further review revealed a treatment order, dated 5/18/19, for the right ischeal tuberosity daily until resolved. There was no documentation that the treatment was done on 5/19/19 at 8:00 PM as scheduled. Interview with the DON on 5/23/19 at 10:10 AM confirmed that the the pressure ulcers were facility acquired and interventions were not in place to promote healing, including repositioning at least every two hours and off loading at least every two hours while in the wheelchair. The DON confirmed that sitting in the wheelchair with a pillow and mechanical lift sling over the wheelchair pressure reducing cushion reduced the effectiveness of the seat cushion. Further interview confirmed that the treatments were to be done as ordered to promote healing as scheduled and skin assessments completed weekly to include all open areas to ensure healing without complications. The DON confirmed that disposable gloves were to be removed after soiled dressings were removed and hand washing done before clean gloves were donned to reduce the risk of cross contamination. Further interview revealed that the residents continued with non compliance with interventions to prevent and promote healing of pressure ulcers and further assessments needed to completed to determine the reasons and possible interventions to obtain compliance. Review of the facility policy Prevention and Management of Wounds, dated 5/21/19, revealed the Policy Statement An interdisciplinary approach to pressure ulcer treatment encourages nurses and therapists to work closely together to assess risk and intervene with preventative measures such as pressure relieving devices and proper positioning. The Wound Care Coordinator and/or licensed nurse shall be designated as being responsible for prevention and treatment of [REDACTED]. |
2020-09-01 |