| 60 |
SANDIA RIDGE CENTER |
325032 |
2216 LESTER DRIVE NE |
ALBUQUERQUE |
NM |
87112 |
2017-03-20 |
224 |
H |
0 |
1 |
30NH11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure that residents were free from neglect for 1 (R #13) of 1 (R #13) residents reviewed for wounds by not notifying the HCP (healthcare provider) of the development of R #13's bilateral (both) heel ulcers. This deficient practice resulted in inconsistent and inaccurate monitoring of bilateral heel ulcers and lack of physician orders for treatment which allowed for R # 13's bilateral heel ulcers to worsen. The findings are: [NAME] Record review of the Nursing Assessment-Initial (Admission) dated 12/15/16 revealed Integumentary (skin) assessment describing skin as occasionally moist, normal for ethnicity skin color, warm, and without skin impairment present. B. Record review of the Progress Notes revealed the following: 1. On 12/23/16 resident had a new onset/change in skin integrity as evidenced by ulcer-pressure. The location is identified as skin breakdown to bilateral heels noted. 2. On 12/28/16 the resident had a skin injury/wound that was previously identified and described the area as pressure area location bilateral wounds to heels. 3. On 01/04/17 the resident had previously identified injury/wound and described the wounds as located on bilateral heels. 4. On 01/26/17 a skin injury was present that had previously been identified and was evaluated and the location was pressure area. 5. On 03/02/17 a previously identified skin injury/wound was present and located on bilateral heels. 6. On 03/13/17, bilateral heel wounds were found by the CNP (certified nurse practitioner). C. Record review of the Skin Check documentation revealed: 1. Skin check documentation dated 12/28/16, 01/04/17, 01/26/17, and 03/02/17 revealed a skin injury/wound was identified, the wound was not new, was a pressure type wound, and was located on bilateral heels. 2. Skin check documentation dated 01/11/17, 01/18/17, 02/02/17, 02/09/17, 02/16/17, 02/23/17, and 03/09/17 revealed no skin injury identified. 3. Skin check documentation dated 03/13/17 revealed a skin injury/wound was identified, the wound was not new, and described the wound as diabetic ulcers bilateral heels. D. Record review of the Skin Integrity Report revealed 1 entry dated 03/13/17 regarding bilateral heel ulcers indicated the following: 1. Left Heel described wound as diabetic, 100 % necrotic eschar (dead tissue), measuring 3.2 cm (centimeters) length, 4.0 cm width, 2. Right Heel described wound as diabetic, 100 % necrotic eschar (dead tissue), measuring 3.5 cm length, 3.7 cm width, E. Record review of the physician orders, Medication Administration Record, [REDACTED]. F. Record review of the Care Plan dated 05/08/16 revealed no care plan focus, goals, or interventions related to R #13 actual bilateral heel ulcers. [NAME] Record review of the physician progress notes [REDACTED].> 1. On 01/23/17 physical exam Skin: Inspection: No rashes or ulcers on exposed skin. 2 .On 02/16/17 physical exam Skin: Inspection: No rashes or ulcers on exposed skin. 3. On 03/13/17 physical exam Skin: Bilateral wounds on heels, L (left) heel with drainage and foul smelling. H. On 03/16/17 at 8:35 am, during interview with the Unit Manager (UM) #3, she confirmed she was not notified of R # 13's initial documentation of bilateral heel ulcers by facility nursing staff. She stated she was notified of the bilateral heel ulcers by the CNP on 03/13/17. The UM #3 verified there were no physician orders related to wound care until the CNP notified her of the wounds on 03/13/17 nor were there care plans in place related to the actual wounds prior to that. I. On 03/20/17 at 8:36 am, during interview with the CNP, she confirmed she is R # 13 primary medical provider. She stated staff did not notify her of R #13 bilateral heel ulcers and she found them herself on 03/13/17. She described the left heel wound as moist and smelled bad. She described the right heel wound as mostly dry and about the same size. When asked if she would call his wounds pressure ulcers, she replied yes. She stated she observed the resident without a heels up cushion (a cushion used to lift heels up off the bed to alleviate pressure) and went to the UM #3 to notify her that the staff needed education regarding wounds. [NAME] Record review of emergency room Discharge report dated 03/19/17 revealed R # 13 sent to emergency room regarding bilateral heel ulcers. K. Record review of the facility policy and procedure Skin Integrity Management revealed: 1. Identify patient's skin integrity status and need for prevention, intervention or treatment modalities through review of all appropriate assessment information. 2. Include all patients who have newly identified skin impairments on the Center's 24 hours summary report. 3. Perform skin inspection on admission/re-admission and weekly. Document on treatment administration record (TAR) or in Point click care (PCC). 4. Perform wound observations and measurements and complete Skin Integrity Report upon initial identification of altered skin integrity, weekly, and with anticipated decline of wound. 5. Perform daily monitoring of wounds or dressings for presence of complications or declines and document. 6. Develop comprehensive, interdisciplinary plan of care including prevention and wound treatments as indicated. 7. Document daily monitoring of ulcer site, with or without dressing. |
2020-09-01 |