| 52 |
SANDIA RIDGE CENTER |
325032 |
2216 LESTER DRIVE NE |
ALBUQUERQUE |
NM |
87112 |
2018-03-14 |
686 |
G |
0 |
1 |
YN7D11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to adequately monitor (through skin assessments) and prevent skin breakdown that led to pressure sores for 1 (R #38) of 1 (R #38) residents looked at for pressure injury/sores and skin breakdown. This deficient practice contributed to R #38 having multiple pressure sores (areas of damaged skin caused by staying in one position for too long) which commonly form where your bones are close to your skin, such as your ankles, back, elbows, heels and hips due to (MASD) Moisture Associated Skin Damage (which is the general term for inflammation or skin erosion caused by prolonged exposure to a source of moisture such as urine, stool, sweat, wound drainage, saliva, or mucus), creating more issues with nutrition and requiring wound treatment that creates pain. The findings are: [NAME] Record review of the Shower sheets indicated that during a shower dated 01/29/18 that R #38 had redness/rash and there was an open area. B. Record review of the Weekly Skin Check Assessments for R #38 indicated that a skin check was done on 12/22/17 and 12/29/17 and there was not another Skin Assessment completed until 02/28/18. C. Record review of the Skin Integrity Report that the DON fills out, indicated that on 01/28/18 and 02/06/18 that R #38 had Moisture Associated Skin Damage (MASD). D. Record review of the Nursing Progress Notes dated 02/04/18, indicated that Resd (resident) appeared very weak and dehydrated. Fluids encouraged and 3 cups taken during shift . [MEDICATION NAME] (a foam dressing suitable for a wide range of wounds like venous leg ulcers, pressure ulcers or diabetic ulcers) intact on coccyx area for protection. Very red open areas on groin areas with clear fluid drainage. Cleansed with warm soapy water and barrier cream applied. E. Record review of the Nursing Progress Notes dated 02/08/18, indicated that . Open area/redended (sic) area noted to coccyx. Dressing applied. Barrier cream applied to groin (sic) and buttocks area. Repositioned on side. F. Record review of the (name of the hospital) History and Physical Addendum by (name of person) for R #38 dated 02/10/18, indicated that Nursing notes severe skin breakdown in groin and pressure ulcer at heel. Will have wound care evaluate. [NAME] Record review of the (name of hospital) Wound Care/Ostomy Forms, Plan of Care: indicated that on 02/11/18 the head to toe skin assessment determined that R #38 had Noted R (right) lateral heel unstageable pressure injury. Wound over heel with tan slough (a layer or mass of dead tissue separated from surrounding living tissue, as in a wound, a sore, or an inflammation) throughout. Foam dressing in place, peeled back to assess . Positioned patient off wound using pillow. Bilateral (affecting both sides) inner thigh, labia majora, Please define perineum (the area between the anus and the scrotum or vulva) and inner buttocks denuded (Denuded means skin gone via chemical means (urine, feces, sweat)). MASD likely from urine leakage .L (left) inferior and superior coccyx (tail bone) with unstageable pressure injuries. Circular wounds over bony prominence. Tan slough throughout both. Non blanching (to cause to become pale, by using digital pressure). No s/s of infection. Blancable redness over entire sacrococcoygeal (pertaining to both the sacrum and coccyx (the tailbone)) area . H. Record review of the care plan dated 12/25/17 indicated that one of the interventions for skin breakdown was to do Weekly Skin Assessments by the licensed nurse. I. On 03/08/18 at 2:32 pm, during an interview with Director of Nursing (DON), she stated that R#38 was originally admitted for a right non surgical leg fracture. She stopped eating for three days so she was sent out to psych (psychiatric) services. Psych services sent her to (name of hospital) and they performed surgery on her right leg fracture and sent her back to this facility. After the surgery she thought that R #38 was in a cast and that it was not removable, but it was a removable cast. When asked if the right heel was being checked, the DON stated that she was not looking at it and that there was a failure on the part of the facility. [NAME] On 03/08/18 at 4:42 pm, during an interview with Licensed Practical Nurse (LPN) #4, she stated that R #38 wouldn't drink enough. She stated that she knew R #38 was dehydrated because of the dry skin, poor skin turgor and cracked lips. She also stated that her pulse was often times high. She stated that R #38 was incontinent and had diarrhea. LPN #4 also stated that if R #38 was having diarrhea she would not give R #38 her stool softeners. LPN #4 also stated that R #38 did have an open area on her Coccyx (referred to as the tailbone), and they were putting cream and a foam dressing on it. When LPN #4 was asked about R #38's heel she stated that she did not have an open area on her heel. K. On 03/12/18 at 9:12 am, during an interview with the Director of Nursing (DON), she confirmed that on the Activities of Daily Living (ADL) flowsheet R #38 was having constant watery stools for (MONTH) (YEAR). She also stated that if a resident was having constant watery stools they should not be getting stool softeners. This could cause skin breakdown and diarrhea depending on fluid intake. The reason that stool softeners are usually prescribed is for residents on opiod (drugs that act on the nervous system to relieve pain) pain medications. L. On 03/12/18 at 9:47 am, during a second interview with the DON, she stated that R #38 had a removable boot but she thought it was a cast. It was removable but she wasn't looking at it. She stated that R #38 did have Moisture Associated Damage and because of this R #38 could have been raw, maybe bloody, because of the wiping when she was incontinent. The DON also stated that the dehydration can contribute to Urinary Tract Infection (UTI's). [MEDICAL CONDITION] (potentially life-threatening complication of an infection) could have been caused by the [MEDICAL CONDITION] but I can't say the UTI is what caused it. The Uropethay (occurs when urine cannot drain through a ureter) could have caused [MEDICAL CONDITION]. It's hard to know and the hospital didn't know either. M. On 03/14/18 at 9:10 am, during an interview with Certified Nursing Assistant (CNA) #14, she stated that R #38 had a red bottom with severe diarrhea 3 or 4 times per shift. She also stated that R #38 was not drinking enough fluids and not eating. CNA #14 stated that they apply cream and put on a foam dressing over that area. She stated that they (the CNAs) were telling the nurses about the poor food and fluid intake, the redness and the diarrhea. N. On 03/14/18 at 9:10 am, during an interview with RN #3, he stated that the incontinence could have contributed to R #38 having an open area. He also stated that the day that R #38 went out to the emergency room (ER), she had lost a lot of weight in a short period of time. Like 14 pounds in ten days or two weeks. He stated that R #38 wasn't eating or drinking on and off since admission. O. On 03/14/18 at 10:27 am, during an interview with the DON, she stated that she had a conversation with the Power of Attorney (POA) sometime after 02/09/18. The POA reported to her that R #38 had an unstageable (full thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar in the wound bed) pressure ulcer to the right heel. The DON stated that R #38 did not get any of the pressure ulcers at the facility, that R #38 got the pressure ulcers while at the hospital. The DON stated that she was aware of the Moisture Associated Damage on her Coccyx and she was actively looking at this area. When asked about the lack of assessments for R #38, the DON indicated that the nurses are supposed to be doing skin assessments and that probably when R #38 returned from the hospital the first time (early (MONTH) (YEAR)) she is not sure that she triggered for skin assessments and that this is probably why they weren't done. |
2020-09-01 |