cms_OR: 1501
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| rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1501 | FOREST GROVE REHABILITATION AND CARE CENTER | 385155 | 3900 PACIFIC AVENUE | FOREST GROVE | OR | 97116 | 2019-07-16 | 684 | E | 0 | 1 | 0GGS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review it was determined the facility failed to ensure orders were in place to treat and monitor surgical sites and to provide bowel medication and treatment when indicated for 4 of 8 sampled residents (#s 28, 35, 53, and 225) reviewed for non-pressure skin conditions, constipation and unnecessary medication. This placed residents at risk for infection, worsening skin conditions and impacted bowels. Findings include: 1. Resident 225 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 7/8/19 at 2:19 PM Resident 225 was observed to have an ACE bandage wrapped around her/his lower left leg, with only the resident's toes exposed. The resident was observed to have several surgically implanted pins, which extended out from the resident's skin and attached to an external stabilizing cage on her/his lower left leg. The tops of the pins were visible, but the bottom of the pins, where the pins entered the skin, were not visible due to the bandage. On 7/9/19 at 11:33 AM the same bandage was observed covering the resident's left lower leg. Resident 225 stated the bandage was present since her/his surgery prior to admission to the facility. Resident 225 stated staff did not monitor her/his skin under the bandage where the pin sites and additional incisions were located. A review of the resident's 7/2019 TAR indicated the pin sites were to be monitored for signs of infection on each shift. Documentation on the TAR indicated various staff, including Staff 19 (RN) and Staff 17 (LPN), monitored the pin sites on each shift since the resident's admission. No evidence was found in the resident's clinical record to indicate any treatment for [REDACTED]. On 7/10/19 at 2:05 PM Staff 19 (RN) stated Resident 225's left lower leg was to be assessed on each shift. Staff 19 stated he had not yet seen Resident 225's leg on his shift, but he was on his way to look at it. On 7/10/19 at 2:15 PM Staff 19 was observed to provide treatment to the resident's leg incision and pin sites. Staff 19 stated wound care to the incision and pin sites was to be completed once per day. As the bandages were removed the resident expressed that was the first time she/he saw the wounds since surgery. No signs of infection or skin deterioration were observed. On 7/10/19 at 2:28 PM Staff 2 (DNS) acknowledged there was no order in place to provide treatment to the resident's incisions and pin sites. Staff 2 further acknowledged it was not possible for staff to assess the resident's pin sites or incisions for signs of infection without removing the bandage. On 7/10/19 at 2:31 PM Staff 17 acknowledged documentation indicated she monitored Resident 225's pin sites for infection. Staff 17 acknowledged she did not remove the bandage in order to assess the pin sites for infection. Staff 17 stated she looked at the skin adjacent to the bandage and determined there was no infection present. On 7/10/19 at 2:59 PM Staff 19 acknowledged documentation indicated he monitored Resident 225's pin sites for infection. Staff 19 acknowledged he did not remove the bandage in order to assess the pin sites for infection. Staff 19 stated he looked at the skin adjacent to the bandage and determined there was no infection present. Staff 19 acknowledged the bandage he removed from Resident 225 at 2:15 PM was in place since the resident's admission to the facility. During an interview on 7/10/19 at 3:08 PM with Staff 2 and Staff 4 (Corporate RN) both staff acknowledged the facility did not obtain orders for treatment of [REDACTED]. Staff 2 stated she previously told one of the nurses on staff to obtain treatment orders but it was not done. 2. Resident 28 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. The 2/2019 Facility Bowel Protocol indicated the following: -If a resident did not have a bowel movement in three days, Milk of Magnesia (MOM) was to be given. -If there was no bowel movement by the following shift, a [MEDICATION NAME] suppository was to be given. -If the resident continued without a bowel movement by the next shift a Fleet enema was to be given. -If the resident exceeded four days without a bowel movement, the licensed nurse will complete an abdominal assessment and the physician will be notified for further orders. Resident 28's bowel records indicated she/he did not have a bowel movement on the following occasions: -6/14/19 through 6/17/19 (four days without a bowel movement) -6/25/19 through 7/4/19 (ten days without a bowel movement) The 6/2018 MAR indicated the resident did not receive MOM, did not receive a [MEDICATION NAME] suppository, or a Fleets enema. There was no indication in Resident 28's medical record to indicate the resident was assessed by a nurse after the two identified instances when the resident did not have a bowel movement. On 7/11/19 at 11:22 AM Staff 5 (CNA) stated Resident 28 was incontinent of bowel and bowel movements were documented in the record. No evidence was found to indicate Resident 28 experienced an outcome related to the lack of bowel care. On 7/11/19 at 3:57 PM Staff 2 (DNS) acknowledged Resident 28 did not have a bowel movement on the identified days and bowel protocol interventions were not implemented. 3. Resident 35 was admitted to the facility in 2013 with a [DIAGNOSES REDACTED]. Review of the facility's 2/2019 Bowel Protocol indicated the following: -If a resident did not have a bowel movement in three days, Milk of Magnesia (MOM) was to be given. -If there was no bowel movement by the following shift, a [MEDICATION NAME] suppository was to be given. -If the resident continued without a bowel movement by the next shift a Fleet enema was to be given. -If the resident exceeded four days without a bowel movement, the licensed nurse will complete an abdominal assessment and the physician will be notified for further orders. Review of the resident's physician orders [REDACTED]. -MOM after evening of third day of no bowel movement. -[MEDICATION NAME] suppository if no bowel movement by morning of the fourth day. -Fleets enema in the afternoon of the fourth day of no bowel movement. Review of Resident 35's bowel record indicated she/he did not have a BM from 6/30/19 through 7/4/19 (five days). The (MONTH) 2019 MAR indicated the only bowel care medication Resident 35 received was a [MEDICATION NAME] suppository on 7/5/19, on the sixth day of no bowel movement. On 7/12/19 at 8:45 AM Staff 2 (DNS) confirmed Resident 35 did not receive bowel care medications as ordered. 4. Resident 53 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. The 2/2019 Facility Bowel Protocol indicated the following: -If a resident did not have a bowel movement in three days, Milk of Magnesia (MOM) was to be given. -If there was no bowel movement by the following shift, a [MEDICATION NAME] suppository was to be given. -If the resident continued without a bowel movement by the next shift a Fleet enema was to be given. -If the resident exceeded four days without a bowel movement, the licensed nurse will complete an abdominal assessment and the physician will be notified for further orders. The 6/2019 MAR and TAR indicated Resident 53 was to receive the following: -MOM if no bowel movement on the third day. -PRN Ducolax Suppository if no bowel movement on the fourth day. Review of bowel records from 6/2019 revealed the following days Resident 53 went longer than three days without a bowel movement: -6/10/19 until 6/17/19 (seven days) -6/25/19 until 6/30/19 (five days) Review of the 6/2019 MAR and TAR revealed the following: -MOM was given on 6/15/19 and was not effective. -MOM was given again on 6/16/19 and the effectiveness was not documented. -MOM was given on 6/27/19 and the effectiveness was not documented. -MOM was given on 6/29/19 and was effective. -No suppository was given to Resident 53 during the month of 6/2019. On 7/12/19 at 8:41 AM Staff 2 (DNS) acknowledged the bowel care protocol was not followed for the identified dates. She further acknowledged the 6/2019 MAR indicated the MOM given on 6/29/19 was effective but the bowel record did not indicate Resident 53 had a bowel movement until 6/30/19. | 2020-09-01 |