cms_NE: 97
Data source: Big Local News · About: big-local-datasette
| rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 97 | AZRIA HEALTH MONTCLAIR | 285054 | 2525 SOUTH 135TH AVENUE | OMAHA | NE | 68144 | 2018-09-17 | 580 | D | 1 | 1 | XOYL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review and interview: the facility failed to notify the physician of the presence of a pressure ulcer (a localized injury to the skin/underlying tissue usually over a bony prominence, as a result of pressure or pressure in combination with shear and /or friction) to obtain treatment orders at the time of admission to promote healing of a pressure ulcer for 1 (Resident 105) of 5 residents reviewed with pressure ulcers. The facility census was 126. Findings are: Record review of a facility Policy and Procedure for Skin and Wound Management standard dated revised (MONTH) (YEAR) revealed the following policies: - A resident having pressure sores receives necessary treatment and services to promote healing and prevent infection: Pressure Ulcer Skin Condition: - Initial identification of a new pressure ulcer will include an assessment and measurement of the wound. Documentation of findings, assessment results and notification of the physician and family will be made in the residents clinical record. Treatment: - The treatment plan will be specific for each individual resident as directed by the physician. Appropriate treatment will address length, width, depth, odor, drainage, pain, wound bed and surrounding skin. Evidence of slough, necrotic tissue or infection should be communicated to the physician and treated accordingly. Record review of Resident 105's Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/9/18 revealed that Resident 105 was admitted to the facility on [DATE] with 1 unhealed pressure sore that was unstageable due to coverage of the wound bed by slough (full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough and /or eschar) and/or eschar (thick, leathery, frequently black or brown in color, necrotic (dead) or devitalized tissues that has lost its usual physical properties and biological activity. Eschar may be lose or firmly adhered to the wound.) The MDS identified that the pressure ulcer was covered by Eschar. Record review of a Braden Scale ( a risk assessment for pressure ulcers) dated 8/4/18 identified that Resident 105 was at high risk for the development of pressure sores with a score of 15. A score of 20 and below was considered to be high risk. Record review of a nursing Admission Summary Progress Note dated 8/2/18 identified that Resident 105 had a pressure ulcer to the heft heel that measured 4 centimeters (cm) by 1.4 cm. Record review of Resident 105's Skin Assessments revealed the following measurements and description of Resident 105's pressure ulcer to the left heel: - 8/3/18: left heel pressure 4 cm x 1.4 cm unstageable, black dry/eschar to left heel - 8/10/18 left heel pressure 4 cm x 1 cm, black dry eschar/scab to left heel - 8/18/18 left heel not identified on the skin assessment, identified no alteration in skin integrity - 8/23/18: left heel pressure 1.4 x 1.3 0.3 cm, stage 3, Wound has about 50 percent eschar to the wound bed, recommend alginate AG with 4 by 4 bordered gauze, change q (every) 3 days and prn (as needed) soiled or dislodged dressing. - 9/1/18: left heel pressure 1.1 x. 75 x .2 - 9/8/18: left heel pressure, no measurements documented. Observation on 09/12/18 at 08:00 AM with the Wound Care Registered Nurse (RN) confirmed the presence of a pressure ulcer to the left heel. The Wound Care RN confirmed that the wound was open and not covered by eschar. Record review of Resident 105's discharge orders from the hospital and admission orders [REDACTED]. The treatment wound care orders only covered treatments to bilateral lower leg stasis ulcers and did not address treatment of [REDACTED]. Record review of Resident 105's Physician orders [REDACTED]. Cover wound bed with Alginate Silver (a medication used to treat pressure ulcers) and apply bordered gauze. Change every 3 days and as needed for soiled or dislodged dressing. Record review of Resident 105's (MONTH) (YEAR) Treatment Sheets revealed that treatments to the left heel pressure ulcer were not started until 8/27/18, a total of 24 days after admission when the left heel ulcer was first identified on 8/2/18. Interview on 09/13/18 at 09:41 AM with the RN Wound Nurse confirmed that there were no treatment orders for the treatment of [REDACTED]. The RN Wound Nurse confirmed that Resident 105's admission Nursing Assessment Progress Note documentation dated 8/3/18 identified the presence of a left heel ulcer and that treatment orders should have been obtained at the time of admission. Interview on 09/13/18 at 01:05 PM with the Director of Nursing (DON) confirmed that there were no treatments provided or ordered for Resident 105's left heel pressure ulcer until 8/27/18. The DON confirmed that the hospital did not send treatment orders for the left heel wound and there was no follow up with the physician regarding the treatment of [REDACTED]. The facility DON was unable to provide evidence that the physician had been notified of the presence of a heel at the time of admission. The DON confirmed that he expectation would be to notify the physician and obtain treatment orders and that this was not done. | 2020-09-01 |