| 8218 |
CHESTER NURSING CENTER |
425061 |
1 MEDICAL PARK DRIVE |
CHESTER |
SC |
29706 |
2012-05-03 |
323 |
J |
0 |
1 |
WII411 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Recertification and Extended survey, based on observations, interviews, record reviews and review of the facility's policy's entitled Applying A Warm Compress or Soak, Event Report, and Abuse and Neglect, the facility failed to ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 1 resident reviewed for burns. Resident #11 received a burn when a heat treatment was administered incorrectly and not monitored during the treatment. In addition 3 of 4 units were noted to have high hot water temperatures and one of 4 units was noted to have low cool water temperatures. The findings included: Cross Refer to F281 as it relates to the facility failure to ensure resident treatments were performed safely and failure to consistently assess and monitor progress should any harm occur. The facility admitted Resident #11 on 11/18/2011 with [DIAGNOSES REDACTED]. Review of Resident #11's medical record revealed a facility's Event Report that indicated on 3/27/12 at 10:30 AM the nurse was called to resident's room by (CNA), observed red area with two intact blisters to lt (left) knee. Also on mattress beside resident was a biohazard bag with two washclothes (sic) inside and a pillowcase covering it. Resident currently has tx (treatment) of heat to lt knee q (every) shift. Called 11p-7a nurse on duty last night, ask her how she did heat tx. to resident's knee. She stated 'I wet two washclothes (sic), put them in microwave for 2 minutes then put inside a biohazard bag and wrapped a pillowcase around it and laid it on resident's knee'. Further documentation reviewed at the facility did indicate the LPN did not check the progress of the treatment after she became busy with other tasks. In an interview on 5/2/12 at 9:05 AM with the Assistant Director of Nursing (ADON), she stated that the facility uses moist heat unless the physician orders heat packs but the order should have been clarified as to which type of heat to use. When asked if the treatment should have been checked and documented every 5 minutes as written in the policy for moist heat, the ADON stated that the facility does not have check sheets but if the policy says every 5 minute checks they should have been done and documented. When asked if it was normal practice at the facility to heat moist cloths in the microwave for heat treatments, the ADON stated that it was not the normal practice to use a microwave. On 5/2/12 from 9:30 AM to 9:42 AM, 4 nurses were interviewed related to how to use heat for a treatment. RN #2 stated that she would use a heat pack wrapped in a towel. LPN #4 stated she would call the physician to verify the type of heat source to use. LPN #5 stated she would use a heat pack and LPN #6 stated that she would warm moist cloths in the microwave. In an interview on 5/2/12 at 12:35 PM, the physician stated that he had been informed of the incident stating it was a burn 2nd degree. The physician stated that he would expect the nurses to use moist heat when he ordered heat. He stated that he would expect the wound nurse to monitor, measure and document the progression of blisters, pressure ulcers and surgical sites. He also stated that he would expect the facility to re-train/in-service the staff after any incident. Review of the facility's policy entitled Applying A Warm Compress Or Soak indicated .Preparation 1. Verify that there is a physician's order for this procedure .2. Check the resident's skin often. Look for: a. Too much redness b. Skin discoloration .Equipment and Supplies .4. If applying a warm compress: . c. Pitcher of warm water (115 degrees F) .k. Unless otherwise instructed, check the skin of the limb being soaked every five (5) minutes . During the initial tour of the facility on 4/30/12 at approximately 10:45 AM, it was noted the hot water temperature in rooms #22 and #31 on Hall 1 were excessively hot to the touch. The surveyor checked random rooms at approximately 12:20 PM on 4/30/12 with a digital thermometer and the following temperatures were revealed: Room # 29: 122.0 degrees Fahrenheit Room #58: 127.5 degrees Fahrenheit Room #54: 122.4 degrees Fahrenheit Room #20: 122.5 degrees Fahrenheit Room #33: 123.5 degrees Fahrenheit Room #43: 124.3 degrees Fahrenheit On 4/30/12 at approximately 1:50 PM, the surveyor toured with Maintenance Technician #1, the following areas and temperature results were noted as: Hall #1 Shower room sink: 123.0 degrees Fahrenheit Room #26 124.5 degrees Fahrenheit Room #20 125.6 degrees Fahrenheit Room #30 123.0 degrees Fahrenheit Hall #2 Shower room sink: 124.3 degrees Fahrenheit Room #45 123.2 degrees Fahrenheit Room #36 125.7 degrees Fahrenheit Room #38 126.1 degrees Fahrenheit Hall #3 Room #55 128.1 degrees Fahrenheit Room #52 120.0 degrees Fahrenheit Room #59 127.9 degrees Fahrenheit Room #54 122.9 degrees Fahrenheit During an interview with Maintenance Technician #1 on 4/30/12 at approximately 1:50 PM, the Maintenance Technician #1 confirmed he did not know if water temperature checks were routinely performed in residents rooms. On the same day at approximately 2:48 PM, an interview with the Maintenance Director revealed that no one in the maintenance department had checked the main domestic supply temperature that morning. He also stated the facility had not been recording random resident room temperatures since December, 2011 and the facility policy was to have the hot water temperatures be at 115 degrees Fahrenheit or less. He confirmed that the temperature at the main domestic supply was 126.3 degrees per computerized recording early this morning. The Maintenance Director stated he had already turned the steam valve down and will recheck the temperature at the valve and also in the resident rooms throughout the rest of the evening. On 4/30/12 at approximately 3:50 PM, the Maintenance Director stated he checked the actual temperature at the main boiler, recorded at 140 degrees Fahrenheit, and he had reduced the temperature setting to 115 degrees Fahrenheit. Interview with a facility CNA and a resident was held on 4/30/12 at 3:45PM related to the water temperatures. Both stated that whenever the water was used they mixed the cold with the hot to ensure that the temperature was not at a level that a resident would receive a burn. On 4/30/12 at approximately 1:30 PM, during random resident room water temperature checks, the surveyor noted in the Gaston Wing, Room #64, the hot water temperature was 85.1 degrees Fahrenheit. On the same day at approximately 2:27 PM, the resident in this private room stated, It's always too cold in the shower and my sink. Random hot water temperature checks continued in the Gaston Wing at approximately 2:30 PM and revealed the following temperatures: Room #61 89.0 degrees Fahrenheit Room #64 88.3 degrees Fahrenheit Room #72 93.3 degrees Fahrenheit Room #77 92.8 degrees Fahrenheit On 4/30/12 at approximately 4:30 PM, the surveyor toured the Gaston Wing with Maintenance Technician #1, and revealed the following hot water temperatures: Room #61 88.1 degrees Fahrenheit Room #72 97.1 degrees Fahrenheit Room #77 104.1 degrees Fahrenheit While observing the Maintenance Director checking the hot water temperature in Room #77, the resident of this room questioned, Is it warm enough to shave now?. The Maintenance Director revealed on 5/1/12 at approximately 8:50 AM that he did not have a policy in place to perform routine water temperatures in resident room to ensure safe and/or comfortable water temperatures. On 5/2/12 at 10:30 AM, the Administrator and the Director of Nursing were notified that Substandard Quality of Care and/or Immediate Jeopardy was identified. The Substandard Quality of Care and/or Immediate Jeopardy existed in the facility on 3/27/2012 when Resident #11 received a burn from a heat treatment which was applied incorrectly. Documentation of inservices, observations, and interviews revealed the Allegation of Compliance submitted by the facility on 5/3/2012 had been implemented by the facility and was in practice removing the immediacy of the deficient practice. Facility nursing staff had been educated and were knowledgeable of abuse policies and procedures and the proper use of heat treatments. The Administrator was informed of this on 5/3/2012. The citation at F-323 remained at a lower scope and severity of D. |
2016-06-01 |