| 4987 |
BAYVIEW MANOR |
425067 |
11 TODD DRIVE |
BEAUFORT |
SC |
29901 |
2016-06-16 |
314 |
G |
1 |
0 |
XYM311 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on closed record review, record review, observation, staff interview, review of facility policy the facility failed to ensure that 2 residents (Residents #1 and #2) of 9 sample residents received the care and services necessary to promote healing and prevent the development of pressure ulcers. Specifically, the facility: -Failed to identify and implement measures to promote healing for existing pressure sores. - The facility failed to timely implement measures for preventing development of new pressure ulcers. -The facility ' s failures contributed to the delay in healing and worsening of the resident ' s pressure ulcers. The findings include: The facility Wound Care Policy (dated 10/2010) documents the purpose of this procedure is to provide information regarding the identification of pressure ulcers risk factors and interventions for specific risk factors. Item #6 documents the facility should have a system/procedure in place to assure assessments are timely and appropriate and changes in condition are recognized, evaluated, reported to the practitioner, physician, ad family and addressed. 1. [AGE] year-old sample Resident #1 was originally admitted to the facility on [DATE]. The facesheet indicated Resident #1 s most recent admission from the hospital to facility was on 11/20/15. The resident was admitted for therapy treatment . A hospital physician discharge summary dated 11/20/15, indicated resident #1's primary [DIAGNOSES REDACTED]. Resident #1 was admitted to the facility for skilled therapy. RECORD REVIEW: MINIMUM DATA SET (MDS) According to the most recent MDS, dated [DATE], Resident #1 was totally dependent on staff for all activities of daily living (ADLs) and was non-ambulatory. The MDS indicated the resident refused care at times and had a catheter in place. Resident #1 had a stage 1 or higher pressure ulcer with three unstageable deep tissue injury pressure sores on admission. The MDS indicated Resident #1 had pressure ulcer on prior assessment and received therapy. CARE PLAN : On 11/20/15, an admission temporary pressure ulcer care plan was initiated. The temporary care plan indicated a problem of an unstageable sacral wound and DTI (deep tissue injury) to bilateral feet. The goals indicated pressure ulcer will decrease in size, monitor for incontinence, provide care if soiled, turn q 2 hrs, administer treatment as ordered, measure ulcer monitor depth, odor and drainage at least weekly. A care plan dated 11/26/15, indicated Resident #1 had a potential for skin breakdown related to (R/T) decreased mobility, although documentation indicated no healed pressure sores. The goals indicated skin would remain intact, although the Resident was admitted with pressure sores which were still present by 11/26/16. Interventions included admistration of medications, diet as ordered, labs were to be monitored. Although the resident was identified with multiple pressure sores, other than the temporary care plan, no care plan was updated for indication of the presence of actual pressure sores. No specific goals or approaches were set in regards to healing/worsening of actual pressure sore or prevention of development of more pressure sore. Instead, the care plan set goals and approaches for potential skin breakdown, for a resident with actual pressure sores. PHYSICIAN ORDERS: Admission Physician (MD) orders dated 11/20/15-11/30/15, indicated clean right (R) lateral calf with wound cleanser apply skin prep daily. Clean sacral wound with wound cleanser, apply Duoderm MWF. Clean the left (L) heel wound with wound cleanser apply skin prep daily. Clean (R) heel and lateral foot with wound cleanser apply skin prep daily. Admission skin assessment dated [DATE], indicated Resident #1 had a scab to the middle of his head, a bruising and an unstagable necrotic area measuring 6.5 cm to 8.5 cm to the sacral area. The assessment indicated multiple bruises to both arms, scabs, bruising were noted to the left foot and toes. The assessment indicated multiple bruises to the right leg, the right heel was red with bruising measuring 3.5cm x 6.0cm and multiple bruised right toes (middle and 3rd toes). A Wound Assessment Report dated 11/20/15, indicated Resident #1 was admitted with the following wounds: a. An unstageable sacral wound with slough/eschar. The wound had scant seranguineous drainage, and in length (L) 6.50 cm X width (W) 8.5 cm X depth (D) 0.0 cm. The wound had no infection. The wound bed had [MEDICATION NAME] tissue, granulation tissue, slough and eschar. The wound edges had well defined and normal healthy tissue. The physician was notified of the wound status. b. The Wound Assessment Report dated 11/20/15, further indicated a wound to the top of lateral (R) right foot , The measurements indicated were : (L) 1.50 cm X (W) 1.50 cm X (D) 0.0 cm. The wound had [MEDICATION NAME] tissue with granulation, and the surrounding skin was normal. The (R) lower extremity had normal color, normal temperature and was warm to touch. The skin had normal elasticity. c. On 11/20/15 the left heel was assessed with [REDACTED]. The measurements indicated were : (L) 14.50 cm X (W) 3.5 cm X (D) 0.0 cm. The wound had [MEDICATION NAME] tissue with granulation, and the surrounding skin was normal. The left lower extremity had normal color, normal temperature and was warm to touch. The skin had normal elasticity. Although, the resident had deep tissue injury to the left foot, the care plan indicated no floating of the injured foot. As indicated above, Resident #1 was admitted with multiple pressure sores and deep tissue injury, no specialized mattress was ordered, no documentation or care plan indicated floating of the left heel was initiated for Resident #1. There were no specific interventions in place for prevention of worsening of existing pressure sores or prevention of facility acquired pressure sores, as indicated by the Director of Nursing on 6/17/16, below. Nurse ' s notes dated 12/1/15, in pertinent parts indicated, Resident #1 had new blisters and bruising to the right lateral calf and low air loss mattress was initiated for the resident, after he acquired more skin breakdown. A Wound Assessment Report dated 12/1/15 revealed a nursing assessment of the resident ' s right shin. The Wound Assessment Report documented a new right lateral shin pressure ulcer identified on 12/1/15. The pressure ulcer was unstagable due to slough/eschar. The right shin wound measured 23.00 (L) x 10.00 (W) x 0.0 cm (D). Nurse ' s assessment furtherdescribed an area with multi color with a small area of eschar to the top of the wound (towards the knee) area with presence of fluid. The Wound Assessment Report indicated, the physician was notified and ordered a low air loss mattress, after the resident acquired the above pressure, 10 days, after he was admitted to the facility. Wound Assessment Report indicated resident refused to get out bed at times and wife was aware. However, a review of nurses documentation revealed the resident had no refusals for getting out of bed or refusals for wound treatment between 11/20/15 and 12/1/15. On12/1/15 Physician (MD) orders indicated, place Resident#1 on a low air loss mattress, after the Resident acquired a pressure sore to shin. Again, there was no indication the care plan was updated for indication Resident #1 had acquired skin breakdown to his shin on 12/1/15 or indication a low air loss mattress was initiated on that date, as ordered by the Physician. STAFF INTERVIEWS: Wound Care Nurse Interview: The Wound Care Registered Nurse (WCRN) was interview on 6/17/16 at 4:00 PM. In the interview with the WCRN, she confirmed the current care plan was inaccurate. The WCRN stated the care plan erroneously indicated care for potential skin breakdown, did not identify actual skin breakdown for a resident with actual skin breakdown. The WCRN stated she initiated the temporary care plan but did not initiate the care plan dated 11/26/15. The WCRN stated the skin issues she identified on the interim care plan should have been carried over onto the final care plan but they were not. The WCRN stated, she would have care planned each one of the wounds, then would have identified Resident #1 ' s risk for further skin breakdown related to his decreased mobility, incontinence and presence of multiple wounds. Director of Nursing (DON) interview: On 6/17/16 at 8:11 PM, the DON was interviewed. In the interview, the DON stated the facility regular mattresses were rated as pressure relief mattresses. The DON stated, in good judgment Resident #1 should have been placed on a low air loss mattress, as the specialized mattress was better for prevention of additional pressure sites and also easier for positioning and turn, created less friction therefore less risk of sheer for resident #1. The DON confirmed Resident #1 ' s assessment indicated Resident # 1 was a high risk for pressure sores as he was admitted with multiple pressure sores and should have been placed on a low air loss mattress on admission. The DON indicated clinical judgment would have been to place Resident #1 on a low air loss mattress on admission to the facility. The DON further confirmed, each one of the pressure wounds should have been identified on the care plan. The DON stated the care plan should have indicated the Resident was at risk for further skin breakdown related to his decreased mobility, incontinence and presence of multiple wounds. The DON confirmed the care plan should have identified the presence of actual pressure sores, goals and interventions for the actual skin breakdown. Within twelve days of admission, nurses notes indicated Resident #1 had acquired another pressure sore to his right shin and no specialized mattress had been initiated by that time, the facility failed to identify and intiate timely measures for prevention of further skin breakdown, for a resident who was admitted with unstageable skin breakdown. The facility failed to update care plan with proper care and prevention of pressure ulcers. 2. Resident #2 was admitted to the facility original admitted [DATE] with readmitted [DATE] with [DIAGNOSES REDACTED]. Annual MDS dated [DATE] Brief Interview Mental Status (BIMS) 11 coded for behaviors towards others; resident coded for total dependence on staff for all levels of care with 2+ person assistance; receives tube feeding, has limited functional range of motion of both upper and lower extremities; incontinent of bowel and bladder; at risk for pressure ulcers and falls. Quarterly MDS 3/9/16 BIMS 5, coded for resisting care 4 to 6 days; resident completely dependent on staff all activities of daily living (ADLs), impairment of both upper and lower extremities; incontinent of bowel and bladder; assessed as frequently having pain; no falls during the assessment period; at risk for pressure ulcers. Care Area Assessment summary dated 12/29/15 triggered for these care areas cognition, mood/depression, nutritional status/dehydration, communication, pain, ADL functions, pressure ulcers, falls, and [MEDICAL CONDITION] drugs. Care plans dated 12/4/15 with latest revision date of 6/15/16 revealed the resident problems included at risk for skin breakdown related to decreased mobility, fragile skin, incontinent B&B, [MEDICAL CONDITION] skin on back observe for skin breakdown, and report findings to MD, assess skin weekly and record findings; notify MD of any abnormal findings; turn and reposition during rounds and PRN; ensure staff places soft or cushioned nasal cannula on resident; treatment as ordered by MD; provide low air mattress and heel protectors to both heels per order. Review of the Unit ' s Weekly Summary Schedule documents the following instructions weekly summaries are to be completed on all Medicare A residents on assigned days. Complete body audits must be done. Weekly summaries will be checked by the unit manager. If weekly summary is not completed you will be called in to complete it. According to the schedule Resident #2 was scheduled for weekly summaries on Saturday 7p-7a shifts. A review of the weekly summaries obtained from the wound care nurse revealed summaries for the following dates 4/9, 4/16, 5/7, and 5/14/16. Each summary identifies Resident #2 had reddened areas on both ears from the nasal oxygen tubing. The facility was unable to provide any documentation related to assessing this resident ' s reddened areas on the ears after 5/14/16 weekly summary. Nurse ' s notes dated 6/9/16 at 7:00am document the CNA providing care noted an open area behind the left ear. Nurse cleaned and prepped area and covered with bandage. Responsible Party notified and obtained a physician order [REDACTED]. However the facility failed to complete a body audit sheet per facility policy when residents receive shower. MD orders 6/9/16 clean area behind ear with wound cleanser and bandage prn. Monitor area for signs and symptoms of infection every sift convert O2 mask until area healed. 6/15/16 9:45am -During initial tour resident was observed in bed positioned on back; HOB elevated 15 degrees with tube feeding infusing. O2 face mask positioned incorrectly on resident ' s face, not completely covering her mouth and nose, straps putting pressure on resident ' s ears; resident has open area on left ear. Bilateral hand contractures, not wearing splints. 6/15/16 4:45pm Remains positioned on back. Wedge cushion on floor behind the bed. HOB elevated 35 degrees; still no splints bilaterally. CNA checked resident for incontinence, adult diaper; wearing bilaterally heel protectors. CNA unaware if resident is supposed to wear hand protectors/splints and cannot explain why resident has floor mat at bedside. Oxygen mask placed improperly, CNA readjusted oxygen mask to completely cover face and adjusted straps to relieve pressure on ear. On 6/16/16 at 5:30pm in an interview RN#2 stated if weekly assessment and body audits were completed according to policy the issue of the resident ' s skin break down behind the ear should have been identified earlier. RN #2 states the weekly assessments and body audits reviewed and signed off by unit manager. At this time B wing does not have a unit manager and the issue of incomplete reports has not been addressed. The assessment and body audit sheets go to the WCN who review the sheets and assessment to determine if any residents identified with new break down areas. The WCN should have identified those areas on the resident ' s ears before it developed into an open area. The WCN is also responsible for maintaining those sheets for QA purposes. Interview with WC #1 on 6/16/16 at 7:00pm revealed the staff will send her note a when a resident develops an open area or requires wound care treatment. WC#1 was unaware that she was responsible for assessing residents with gastrostomy feedings. Asked the WC #1 who was responsible for the assessment and body audit sheets, WC#1 responded it was the responsibility of the unit manager. WC#1 stated she did not always review the body audit sheets and weekly summaries. WC#1 then admitted the sheets were maintained in her office but did not know why. Requested the WC#1 to bring the body audit and summaries for the past 8 weeks for Resident #2. The WC#1 provided body audit sheets for 4/30/16 and 5/3/16 (shows redness on resident ' s back and buttock). And weekly summaries for 4/9/16, 4/16/16, 5/7/17 and 5/14/16 which documents the resident with redness on the ears. The sheets were reviewed with the WC#1 confirmed the resident was identified with redness on the ears which was probably the beginning of skin breakdown. The WC#1 stated she had not seen the resident until this morning when the staff brought it to her attention about the resident ' s hands and the resident ' s ears. The facility failed to properly assess Resident #2 after it was identified starting on 4/9/16 to 5/7/16 the resident had reddened areas on the ears from the oxygen tubing. The facility failed to conduct body audits and weekly summaries to assess the resident ' s skin. It was documented on 6/9/16 that the resident had developed an open area behind the ear from the oxygen tubing. |
2019-06-01 |