cms_SC: 3241
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 3241 | HALLMARK HEALTHCARE CENTER | 425326 | 255 MIDLAND PARKWAY | SUMMERVILLE | SC | 29485 | 2020-01-16 | 684 | D | 1 | 1 | SMCX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review, interviews, and review of facility policy, it was determined the facility failed to follow the wound care consultant's (WCC) recommendation to keep the brief unlatched when in bed and failed to assess and measure the wound every week for one (1) resident. (Resident #55) Findings included: Review of the policy titled, Wound Evaluations revised 9/7/17 revealed an evaluation of wounds will be performed on admission, weekly and on discovery. Objective evaluation components included: location/type of wound; measurements; appearance; drainage; odor; presence of undermining/tunneling; healing; pain; [MEDICAL CONDITION]; presence of infection. Review of the clinical record revealed Resident #55 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Review of the Admission Observation form dated 12/13/19 and timed 5:47 PM revealed the resident had no alterations in skin, except for excoriation on the coccyx. Review of Resident #55's Admission Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BI[CONDITION]) score of 15, indicating intact cognition. The MDS revealed the resident required total assistance with transfers and personal hygiene. The resident was always incontinent of bowel and bladder, was at risk for developing pressure ulcers and had no skin alterations. Review of Resident #55's care plan dated 1/8/2020 identified the resident was admitted with excoriation to the sacrum and peri area. The interventions included nursing to do a full body audit weekly, preventative skin care as ordered, Certified Nurse Aides' (CNAs) to assess skin with activities of daily living (ADL) care and report any changes to nurse. Review of the Skilled Charting notes revealed: [DATE] at 6:49 PM the resident had no alteration in his skin. [DATE] at 2:35 AM and at 10:43 AM the resident had no alteration in skin. 12/30/19 at 10:43 AM the resident had no alteration in skin. 12/31/19 at 3:09 AM. the resident had no skin issues. 12/31/19 at 10:49 AM. the resident had scattered bruising on the abdomen and blisters on his thighs. 1/1/20 at 3:16 AM the resident had no skin issues. 1/3/20 at 3:51 AM the resident had no skin issues. [DATE] at 3:51 AM the resident had no skin issues. [DATE] at 12:53 PM the resident had redness to neck area. 1/6/20 at 4:03 AM the resident had no skin issues. 1/8/20 at 3:28 PM the resident had redness to neck area. 1/9/20 at 3:30 PM the resident had redness to the neck area. [DATE] at 2:45 AM the skin section of the skilled charting was not filled out. 1/14/20 at 12:57 AM the resident had no skin issues. The two (2) Weekly Skin assessments completed, revealed: [DATE] at 7:55 PM the resident had redness to the neck area, discoloration to the right hand and redness to the inner thighs and peri area. [DATE]20 at 8:19 PM revealed the resident had redness to the neck area. Review of the only WCC Progress Notes dated 1/6/2020 revealed the resident had a ten by ten (10 by 10) with a depth of 0.1 centimeters (cm) macerated area to the sacrum, dermatologic areas measuring nine by eight (9 by 8) with a depth of 0.1 cm to the left groin and 12 by six (6) with a depth of 0.1 cm to the right groin. The WCC recommend frequent offloading and not latching the brief while in bed. The clinical record lacked accurate and weekly skin assessments including measurements. Observation with Registered Nurse (RN) #2 on 1/15/2020 at approximately 3:00 PM revealed Resident #55 laid flat in bed. RN #2 removed the covers and revealed the resident's brief was taped closed. The RN turned the resident to his right side and revealed an approximate five (5) inch long and approximately three (3) inch wide area on both sides of the inner buttock with the top layer of skin gone and a small amount of bleeding noted. The RN wiped the area with a disposable wipe and applied Zinc ointment over the areas. Interview with the Assistant Director of Nursing (ADON) on 1/16/2020 at 11:57 AM revealed the Licensed Practical Nurses (LPN) cannot measure or assess the wounds. If an LPN was working on the unit, the measurements would not be done. The WCC does the measurements when she comes. The ADON also stated the WCC sends weekly notes to the Director of Nursing (DON). The DON reviews the recommendations and will consult with the physician if needed and would write the order. The ADON stated she did not know about the recommendation to leave the brief open. The ADON also stated she will add it to the Point of Care (POC), (the Certified Nurse Aides care plan). Interview with the DON on 1/16/2020 at 4:57 PM revealed the WCC emails her recommendations to the Unit Manager, the ADON, and now the DON. The Unit Managers are responsible to follow-up on the recommendations. The DON also stated the WCC did not come to the facility this week, since the survey team was in the building. The facility failed to thoroughly assess and provide interventions as recommended for this dependent resident, which resulted in further deterioration to skin. | 2020-09-01 |