| 10 |
RYDER MEMORIAL HOSPITAL INC |
405018 |
355 AVE FONT MARTELO |
HUMACAO |
PR |
792 |
2017-05-04 |
309 |
D |
0 |
1 |
ZOYB11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a recertification extended survey, ten records reviewed (RR), interviews with the Registered Nurse in charge of resident care (employee #8), the Infection Control Preventionist (employee #7), the Head Physician (employee #6) and the resident (RR #4), policies and procedures (P&P's) related to skin care, pain management and observations performed during monitoring round, performed from 05/02/17 thru 05/04/17, from 8:30 am to 5:00 pm, it was determined that the facility failed to ensure that the nursing staff perform an accurate assessment of a skin burn, to develop a plan of care with interventions for burn care and the implementation of the pain management protocol by all professional staff, as observed in 1 out of 10 RR, (RR # 4). Findings include: 1. Resident #4 is an [AGE] years old male resident who was admitted on [DATE] with a diagnose of Right Foot Ulcer with secondary diagnoses, such as: [MEDICAL CONDITIONS], Hypertension and Alzheimer. During observational tour performed on 05/02/17 at 9:45 am accompanied by The Infection Control Preventionist (employee #7) it was found that resident was bedridden and was accompanied by his son. It was observed that resident has a medicated patch on his right foot sole. During interview with the Infection Control Preventionist (employee #7) performed on 5/3/17 at 9:30 am, she stated the following: The resident has a burn in his right foot sole. According to interview performed to resident's son, this resident was disoriented and he began to walk around the neighborhood. He was using flip flops and apparently, the flip flop was out of his right foot. Probably he was walking over the hot street. We think that is the way that he develop the burn in his right foot sole. It is not an ulcer because the [MEDICAL CONDITION] is not over a bony prominence. It is located at the foot sole. During RR #4 performed on 5/3/17 at 1:00 pm it was found the following: a. On 4/27/17 at 11:30 pm, the physician ordered to implement the skin care protocol. No evidence was found of a diagnose of skin burn. The physician's history and physical examination [REDACTED]. Six days have passed and it was not determined the burn degree. On the Minimum Data Set (MDS), section I -Active Diagnoses, the nurse wrote that resident's active diagnose is Right Foot Plantar Lesion. According to the ICD 10 codification that was written on this section, it is related to a Burn of Unspecified Degree of Ankle and Foot not to a plantar (sole) lesion. No evidence was found of the MDS Coordinator or the Physician to perform the diagnose correction on this section of the MDS. The resident has a skin burn on his right foot sole but no evidenced was found of the burn degree that resident has and could established accurately the diagnose. If the resident's burn would be as a second degree, the ICD 10 codification changes. However, could not be determined the classification of the burn due to lack of documentation on the clinical record. The nursing staff documented the assessment and intervention form that is part of the Protocol for Prevention and Management of Patients with Altered Skin Integrity. However, the nurse that performed the initial documentation in this assessment on 4/27/17, failed to write the risk factors on section A of this form. On section B related to the Nursing Interventions, the nurse failed to place a check mark besides the interventions that applies to the resident's burn care and management. The first item of these interventions are related to ulcer assessment. However, there are items applicable to burn care that were not identified. b. It was found that the nursing staff failed to identify on the daily nursing skin reassessment form that the resident has a burn. This was observed on the nursing notes from 4/27 thru 5/3/17. The nursing staff only wrote right foot sole on the section known as location(Localizacion) which is part of this reassessment form. The anatomical diagram that is attached to the skin reassessment form was not documented by the nurse. She failed to identify on this diagram the location of the burn and how extended is it over the foot sole. To determine if the nursing staff has knowledge of the burn classification and treatment to be provided to this resident, an interview with the Registered Nurse (RN employee #8) was performed on 5/3/17 at 2:00 pm. It was requested to classify the [MEDICAL CONDITION] of resident #4 and how she knows that the patient is improving. Employee #8 stated the following: The treatment provided is as if it were an ulcer and the Infection Control Preventionist takes pictures of it. I think that watching the pictures we can figure out patient's improvement. On the other hand, on the MDS section M for Skin Conditions, on item M1040 related to other ulcers, wounds and skin problems, the nurse placed a check mark besides item c that belongs to other open lesion on the foot. In her handwriting she added (right foot sole area). On item f which belongs [MEDICAL CONDITION](second or third degree) the nurse failed to identify this item. According to professional literature review and to observations performed to the resident's burn performed on 5/4/17 at 11:00 am this [MEDICAL CONDITION] could be a second degree burn. However, no evidence was found on the clinical record documentation of the classification of the resident's burn. c. The surveyor asked the physician (employee #6) if there is a mechanism that help him to determine if the burn lesion is decreasing in size and the healing process is adequate according to the treatment provided. During interview with the head physician (employee #6) performed on 5/4/17 at 8:30 am, he stated the following: The skin burn can be measure, if we want to have an objective criteria to determine if the lesion is decreasing in size. I can write an order requesting the skin burn measurement every 3 days. Through direct observation, one indicator that can help to determine if the healing process is adequate is if granulation tissue is present. However, it was not found written evidence that determine resident's improvement according to the provided care and treatment. During interview with the Infection Control Preventionist (employee #7) performed on 5/3/17 at 9:30 am, she stated the following: We do not perform measurements in burn [MEDICAL CONDITION]. I took a picture during the admission process and on the next (medicated) patch replacement I will take a picture to watch its improvement. However, it was not found on the clinical record documentation performed by the Infection Control Preventionist (employee #7) related to her observations and conclusions after analyzing the burn condition throughout the pictures. d. The skin burn documentation performed by the nursing staff, lacked of the following characteristics on almost of the daily documentation of the skin reassessment form from 4/27 thru 5/2/17: -status of the surrounding skin ([MEDICAL CONDITION], blister, ecchymosis, degree of the burn) -skin characteristics (tunneled, necrosis, depth) -description of the secretions (it has to be mentioned that the nursing staff identified mild secretions but failed to write color, odor and other characteristics of it). e. On the admission's order from 4/27/17 at 11:00 pm, the physician ordered to apply [MEDICATION NAME] over the right foot sole burn on a daily basis. However, on the nursing skin reassessment form from 4/27 and 4/28/17, the nursing staff failed to write the applied treatment. They left blank spaces. On 5/1/17 at 1:20 pm, the head physician changed the skin care treatment to Allevyn AG 7x7 to be put on the right foot sole and to change it every 3 days. However, the nursing staff failed to write this new treatment on the skin reassessment form on 5/2 and 5/3/17. f. During review of the resident plan of care performed on 5/3/17 at 1:00 pm it was found that the problem related to potential for [MEDICAL CONDITION] risk was activated on 4/27/17. Some of the interventions established to work this problem are the following: - daily documentation of the skin condition on the reassessment form - daily assessment of the skin - to apply [MEDICATION NAME] creams over skin or to put [MEDICATION NAME]es - to follow the Protocol for Prevention and Management of Patients with Altered Skin Integrity However, the nursing staff failed to write on the clinical record the observations and interventions performed to the resident according to the plan of care. The nursing staff failed to write on the plan of care the expected results and dates of when it was reviewed. No evidence was found of an ongoing monitoring and review of the plan of care. The problem known as [MEDICAL CONDITION] was also activated on 4/27/17. The nurse identified that resident has an opened lesion on his right foot sole but failed to identify that the lesion is a burn. The nursing staff dated a review of the plan of care on 5/2/17. However, it was not found evidence of previous reviews of the plan of care between the admitted s until 5/2/17. According to these findings, the nursing staff is not aware of how a burn is classified, what to document on the clinical record and when to perform plan of care reviews. 3. The nursing staff failed to perform a daily and an accurate pain assessment. During RR #4 performed on 5/3/17 at 1:00 pm it was found that the head physician (employee # 6) ordered on [DATE] at 11:30 pm to begin the pain protocol. During review of the pain management order form it was not documented by the head physician. He failed to place an order for [REDACTED]. During review of the physician's history and physical examination [REDACTED]. During review of the nurse's skin reassessment form, since 4/27/17 until 5/3/17, it was found that the nursing staff failed to perform a daily pain assessment. This was evidenced by not writing on the Wong Baker's pain scale. The nursing staff failed to identify on this pain scale is resident was having or not pain. During interview with the Infection Control Preventionist (employee #7) performed on 5/3/17 at 9:30 am, she stated the following: Every morning, the Nursing Supervisor performs an observational round with some of the nurses. Among the questions she asks to the residents is, if they have pain. According what I heard from the nursing staff, this resident is not having pain. Sometimes he is disoriented and maybe he can't tell us specifically if he is feeling pain on his right foot. However, on 5/4/17 at 11:00 am, the surveyor requested the Infection Control Preventionist (employee #7) to take out the medicated patch on patient's right foot sole to observe its condition and to determine if resident was in pain. When employee #7 began to pull out the patch, it was observed that the resident moved his right foot backwards and with non-verbal facial gestures, showed that he was in pain. The surveyor asked the resident if he was feeling pain on his foot and he answered Yes. The surveyor asked the resident, in the presence of employee #7: What moment of the day do you feel pain or discomfort? His answer which was very clear, was: When the nurses come to bring care to my foot (he pointed with his finger his right foot). The surveyor asked employee #7, what is the meaning of resident's facial gestures? She answered: Of pain. That he is having pain. According to interview with the head physician (employee # 6) performed on 5/4/17 to determine if he assessed pain on each visit, he stated the following: For that type of burn, he can feel pain. The nursing staff has not referred me that he is having pain. During review of the medication's administration record performed on 5/3/17 at 1:00 pm it was not found physician's orders [REDACTED]. During review of the Physical Therapist (PT) documentation performed on 5/3/17 at 1:00 pm it was found the following: In the PT initial assessment performed on 4/28/17 by the PT and the progress notes from 4/29, 5/1 and 5/2/17 performed by the Physical Therapist Assistant (PTA), it was determined that the PT staff failed to perform an accurate pain assessment. This staff wrote on the pain assessment section the nomenclature of N/A which means: Not applied. They failed to write on the Wong-Baker's scale a zero if patient was not having pain at the moment they offered the physical therapy. During review of the MDS documentation performed on 5/3/17 at 1:00 pm, on section V, related to Care Area Assessment (CAA) summary, item # 19 the care area for pain was not identified by the person who completed the care plan decision form. The facility failed to ensure that the professional staff perform daily accurate pain assessment and interventions according to the plan of care and as established on the Protocol for Pain Management. |
2020-09-01 |