| 908 |
MONUMENT REHABILITATION AND CARE CENTER |
285095 |
111 WEST 36TH STREET |
SCOTTSBLUFF |
NE |
69361 |
2017-08-22 |
309 |
H |
1 |
1 |
2T4P11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number: 175 NAC 12-006.09D Based on observations, record reviews and interviews; the facility failed to ensure that 1) thorough skin assessments were completed at least weekly and dressings were changed as ordered to promote healing of open wounds with ongoing drainage for one current sampled resident (Resident 84), 2) pain was assessed and controlled during wound care for one current sampled resident (Resident 169), 3) ongoing severe pain was identified and managed for one current sampled resident (Resident 15), 4) pain rated severe was assessed and controlled for one closed record (Resident 173) and two current sampled residents (Resident 90 and 10), 5) a resident with an abnormal blood pressure reading was assessed and follow up completed to ensure that the resident didn't experience any adverse effects for one current sampled resident (Resident 84) and 6) a decline in behaviors was assessed and a plan to manage behaviors was developed for two current sampled residents (Residents 29 and 25). The facility census was 107 with 22 current sampled residents and three closed records. Findings are: A Review of the Admission Record, printed 8/9/17, revealed that Resident 84 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observations on 8/8/17 at 11:00 AM revealed the resident seated in the wheelchair with ongoing foul odors noted from dressings at lower extremities. Interview on 8/8/17 at 11:00 AM with the resident revealed they don't change my dressings like they're supposed to. Observations on 8/9/17 at 9:30 AM revealed the resident seated in room in a wheelchair and noted a strong foul smelling odor in the room and the hallway by the resident's room. Interview with the resident on 8/9/17 at 9:30 AM revealed my legs are bleeding, they're supposed to change my dressings two times a day and put some cream on my legs and lucky to get it done every 2-3 days. Further observations revealed the resident removing the dressings from the right lower legs and noted leg swollen with clear, foul smelling weeping drainage dripping down the leg. Observations on 8/9/17 at 1:30 PM revealed the resident seated in the wheelchair in the room for the scheduled treatment and dressing changes to the legs. Noted the foul smelling drainage continued to weep from the lower legs bilaterally and the dressings were removed from the lower legs. The dressing/wraps were intact at the thighs. Further observations revealed LPN (Licensed Practical Nurse) - R, Charge Nurse (assisted by LPN - C, Unit Coordinator), while sitting on the floor in front of the resident, removed the wrap and dressings from the right thigh, cleansed the back of the thigh with a disposable washcloth and then the front of the thigh, applied [MEDICATION NAME] cream as ordered to the back and front of the thigh, wrapped gauze around the thigh and then an ace wrap. Noted that the back of the thigh was not visible to the nurse to assess the resident's skin as the treatment was done. LPN - R removed the ace wrap and dressing from the left thigh and performed the treatment in the same manner. The resident complained of soreness behind the left knee. LPN - R could not visualize the skin at the back of the thigh for an assessment. The resident stated my legs have been bleeding for two days. The resident also complained of pain at the left thigh and lower legs, moaning and grimacing, while the treatments were done at the left thigh and lower legs. Interview on 8/10/17 at 8:00 AM with LPN - R revealed that the resident often removed the dressings from the lower legs and often refused routine bathing. Observations on 8/10/17 at 8:00 AM revealed the resident seated in a recliner in room with legs elevated about ten inches, strong foul odor remained in room. Further observations at 11:00 AM and 2:15 PM revealed the resident seated in the wheelchair, legs not elevated and the strong foul odor remained in the room and into the hallway. Review of the Weekly Skin Check, dated 7/12/17, revealed that the resident had [MEDICAL CONDITION] at the right and left thighs (rear), right lower and left lower front legs, and right lower and left lower legs rear. [MEDICAL CONDITION] is a condition of abnormal accumulation of tissue fluid (potential lymph) in the interstitial spaces. The resident refused to have skin assessment completed. Review of the Weekly Skin Check, dated 7/19/17, revealed that the resident had bilateral lower [MEDICAL CONDITION], right and left thighs (rear), right and left lower legs (front and rear) and dressings were applied as ordered. The resident also had excoriation under both breasts and under the abdominal fold and a wound at the buttock which measured two by two centimeters. The resident had no other areas of concern. Review of the Weekly Skin Check, dated 8/9/17, (none received to review for 8/2/17), revealed that the resident had excoriation under both breasts and under the abdominal fold, and [MEDICAL CONDITION] to the right and left thigh (rear), right and left lower legs (front and rear). Further review revealed no measurements of the swelling to evaluate worsening or improvement. Review of the Treatment Administration Record, dated (MONTH) (YEAR), revealed an order, dated 1/30/17, for compression wraps to both legs, change every 12 hours for [MEDICAL CONDITION] and [MEDICATION NAME] cream to bilateral legs every 12 hours. Further review revealed no documentation that the treatment was done on the day shift on 8/4/17, 8/5/17 and 8/6/19. The treatment was documented as refused on the day shift on 8/7/17 and on the evening shift on 8/2/17, 8/3/17, 8/4/17, 8/6/17, 8/7/17 and 8/8/17. Further review revealed an order, dated 6/6/17, to check buttocks and coccyx daily for skin breakdown and an order dated 7/20/17, for [MEDICATION NAME] cream to buttock every shift. Review of the Progress Notes, dated (MONTH) (YEAR), revealed no documentation of the resident's ongoing refusal of thorough skin assessments or treatments to the legs. Further review revealed no documentation of the ongoing foul smelling weeping drainage from the legs or the status of the open area on the buttock. Interview on 8/15/17 at 9:00 AM with LPN - C, Unit Coordinator, confirmed that complete skin assessments were not completed at least weekly to determine whether or not the treatments were effective. LPN - C confirmed that a complete assessment of the resident's skin condition could not be done while the resident was seated in a wheelchair. Further interview confirmed that the ongoing foul smelling drainage from the legs was not documented or addressed. B. Observations on 8/9/17 at 1:00 PM revealed Resident 169 resting on the bed, positioned on back for wound care. Further observations revealed LPN - Q lifted the resident's right foot to remove the protective boot and the resident complained of pain as the foot was lifted up. The resident said ouch, that is so tender and the resident grimaced and had labored breathing. The resident continued to complain of pain when the right foot was moved for the treatment on the pressure ulcer at the heel with continued verbal complaints of pain, facial grimacing and labored breathing. LPN - Q continued with the treatment and encouraged the resident to take deep breaths. LPN - Q and RN (Registered Nurse) - P turned the resident to left side to continue treatments to pressure ulcers at the right buttock and sacral area. The resident groaned again with pain when the right foot was lifted while repositioned to side. The resident also complained of hip pain when repositioned, when the treatment was done to the sacral area and when positioned again on back. Interview on 8/9/17 at 2:00 PM with the resident revealed that those treatments are so painful. Review of the Medication Administration Record, [REDACTED]. Interview on 8/15/17 at 10:00 AM with LPN - C, Unit Coordinator, confirmed that the resident should have been offered pain medication before the wound care in anticipation of pain. LPN - C confirmed that the nurses should have stopped the treatment when the resident complained of pain, medicated the resident and then continue with the treatment to promote comfort for the resident. C. Interview with Resident 15 on 8/8/17 at 11:20 AM revealed that the resident had back and neck pain. The resident stated that takes pain medications but it still hurts. Observations during the interview revealed that the resident had pained facial expressions and a clenched jaw. Observations on 8/9/17 at 9:45 AM revealed the resident seated in the wheelchair in room with tears in eyes. Further observations revealed dried dark red colored matter on the rim of the urinal on the edge of the garbage container. Interview with the resident on 8/9/17 at 9:45 AM revealed my bladder, back and kidneys hurts so bad. The resident also stated that it has been hurting for several days now with no relief from the pain pills. The resident stated pain pills don't help at all, it hurts so bad that I want to cry, having blood in my urine and I'm supposed to see a doctor. Interview on 8/9/17 at 10:00 AM with RN (Registered Nurse) - P, Charge Nurse, revealed that the resident had chronic neck pain and usually requested a pain pill in the morning. RN - P did not mention the resident's back pain or blood in urine. Observations on 8/9/17 at 11:15 AM revealed the resident seated on the toilet and complains of really bad pain. The resident stated may be passing a kidney stone or something. Further observations revealed the resident had bright red blood in the toilet. Interview on 8/9/17 at 11:30 AM with RN - P revealed that no urology appointment had been made yet to evaluate the resident. Further interview revealed would have the Nurse Practitioner check the resident. Review of the MAR (Medication Administration Record), dated (MONTH) (YEAR), revealed that the resident had a routine [MEDICATION NAME] (narcotic [MEDICATION NAME]). Further review revealed that the resident received [MEDICATION NAME] (Opioid [MEDICATION NAME]), ordered as needed for pain, on 8/7/17 at 8:22 AM, on 8/8/17 at 8:38 AM and 7:12 PM and on 8/9/17 at 8:43 AM for pain rated 9 (severe) on the 1-10 pain scale. Further review revealed documentation that the 8/8/17 at 8:38 AM and the 8/9/17 at 8:43 AM doses were ineffective in relieving the resident's pain. Review of the physician's orders [REDACTED]. Review of the physician's orders [REDACTED]. Interview with the LPN - C, Unit Coordinator, on 8/15/17 at 10:30 AM confirmed that the medical provider should have been notified of the resident's ongoing unrelieved pain and blood with urination sooner to relieve the resident's pain. D. Review of the Admission Record, printed 8/9/17, revealed that Resident 173 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Medication Administration Record, [REDACTED]. Further review revealed that the resident received the first dose on 7/11/17 at 1:00 AM for pain rated 7 (on a pain scale of 1-10 with 10 as the worst possible pain) for right shoulder pain per the Progress Notes. The resident received the next doses at 7:34 AM for right shoulder pain rated 8 and at 4:44 PM for all over pain rated 9. The resident received the pain medication again on 7/12/17 at 4:51 AM for pain rated 7 for right shoulder and right arm pain, at 1:11 PM for right shoulder pain rated 10 and at 9:09 PM for right shoulder pain rated 7. Review of the Progress Notes, dated 7/12/17 at 9:55 AM, revealed that the resident complained on continuous pain to the left upper extremity and the right lower extremity and pain medication offered as needed was effective for a short amount of time, but then the pain returned. The resident was to have an x-ray of the right ankle today due to severe pain. Review of the Progress Notes, dated 7/13/17 at 2:36 PM revealed a new order for [MEDICATION NAME] 10/325 milligrams every 6 hours for pain. Review of the Medication Administration Record, [REDACTED]. Further review of the Medication Administration Record [REDACTED]. Further review revealed no documentation on 7/14/17 or 7/15/17 of how the resident rated the pain. Review of the Progress Notes, dated 7/15/17 at 4:10 PM, revealed that the resident was continuously pulling on the call light cord screaming in sleep, noted body tremors, when the resident was awake was confused and hallucinating about chickens. The on call provider was notified of the resident's change in condition and stated it is probably the dosage increase of [MEDICATION NAME] and new orders were received to discontinue the routine scheduled [MEDICATION NAME] and change back to every eight hours as needed for pain. Further review revealed that at 8:00 PM, the resident continued to have episodes of twitching with [MEDICAL CONDITION] off and on during the day, was unresponsive and grimaced with pain during movement. The provider was notified and orders were received to transport the resident to hospital emergency room for evaluation and then admission. Interview on 8/15/17 at 3:00 PM with LPN - C, Unit Coordinator, confirmed that further assessments of the resident's ongoing pain should have been completed, including causal factors and non- pharmacological interventions in place to control the resident's pain. Further interview confirmed that pain assessments should have continued when the [MEDICATION NAME] was changed to routine dosing to ensure that pain was managed effectively for the resident's comfort. E. Review of the Admission Record, printed 8/9/17, revealed that Resident 90 was admitted on [DATE] with [DIAGNOSES REDACTED]. Interview on 8/9/17 at 10:00 AM with the resident revealed that the right shoulder continued to hurt and rated pain at 7 as it still hurts a lot. Interview on 8/10/17 at 7:15 AM with the resident revealed that the right shoulder and right leg hurt and the resident was rubbing the shoulder and leg. The resident stated that the pain pills help some, but it still hurts. Review of the Medication Administration Record, [REDACTED]. Review of the Medication Administration Record, [REDACTED]. Further review revealed that orders were received on 8/8/17 for routine [MEDICATION NAME] every bedtime. Interview on 8/15/17 at 10:40 AM with LPN - C, Unit Coordinator, confirmed that further assessments of the resident's ongoing pain should have been completed to include potential causal factors and non - pharmacological interventions to manage the resident's pain. F. Review of the Admission Record, printed 8/9/17, revealed that Resident 84 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Medication Administration Record, [REDACTED]. Further review revealed the resident's blood pressure was 195/75 on 7/28/17. Review of the medical record, including the progress notes, revealed no assessment of the resident on 7/28/17 or follow up blood pressure until 8/2/17 with a reading on 163/73. Interview on 8/14/17 at 1:30 PM with LPN - D, Unit Coordinator, confirmed that an assessment and follow up vital signs should have been completed and documented with the abnormally high blood pressure reading on 7/28/17. Further interview confirmed that the resident's condition should have been monitored closely to ensure that the resident's needs were met. [NAME] Review of Resident 29's MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used for care planning), dated 6/10/17, revealed that the resident had no behaviors. Review of the MDS, dated [DATE], revealed that the resident had physical behaviors directed towards others one to three days during the assessment period. Interview on 8/14/17 at 2:30 PM with LPN - Z, MDS Coordinator, revealed that the resident had a documented episode of hitting and kicking staff in the nursing assistant documentation during the assessment period. Further interview confirmed that there was no documentation that the care plan team reviewed the incident, considered the potential causal factors related to the behaviors or developed a plan to reduce the risk for further behaviors. H. Review of Resident 25's MDS, dated [DATE], revealed that the resident had no behaviors. Review of the MDS, dated [DATE], revealed that the resident had physical behaviors directed towards others one to three days during the assessment period. Interview on 8/14/17 at 2:30 PM with LPN - Z, MDS Coordinator, revealed that the care plan team did not address the resident's decline in behaviors, identify potential causal factors or develop a plan to manage any further behaviors directed towards others. I. Interview with Resident 10 revealed the resident had pain that would not go away and the facility hadn't intervened to assist in alleviating the pain. Observation on 8/8/17 at 10:20 a.m. revealed the resident grimaced throughout the interview. Record review of the MDS (Minimal Data Set, a federally mandated comprehensive assessment tool utilized to develop care plans) revealed the resident was assessed with [REDACTED]. Record review of the resident's care plan revealed the resident had right knee pain. Record review of Nurses notes revealed Resident 10 had knee injections for pain on 8/9/17 at the physician's clinic. Record review of facility documentation revealed no pain assessments for Resident 10 were completed before and after knee injection on 8/9/17. Record review of Resident 10's Medication Administration Record [REDACTED]. Record review of Resident 10's electronic medical record revealed there were no formal pain assessments completed since 6/30/17. Interview with LPN (Licensed Practical Nurse)-C on 8/15/17 at 3:00 p.m. revealed LPN-C was the unit coordinator and worked routinely with Resident 10. LPN-C confirmed there were no follow up formal pain assessments or documentation for Resident's pain since 6/30/17. |
2020-09-01 |