cms_SC: 967
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 967 | PRUITTHEALTH- BAMBERG | 425104 | 439 NORTH STREET | BAMBERG | SC | 29003 | 2017-05-05 | 314 | D | 0 | 1 | P4RY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure Resident #87's and Resident #95's pressure ulcers were measured and staged in a timely manner for 2 of 3 residents reviewed for Pressure Ulcers. The findings included: The facility admitted Resident #87 with [DIAGNOSES REDACTED]. Review on [DATE] at approximately 3:37 PM of a form titled, Wound observation and Assessment Form, revealed Resident #87 was in the hospital from [DATE] through [DATE] and was admitted back into the facility on [DATE]. Licensed Practical Nurse (LPN) #2 assessed the pressure ulcers on admission on [DATE]. The Wound Nurse was not available until 4 days later to actually measure and stage the pressure ulcers. An interview on [DATE] at approximately 3:40 PM with Registered Nurse (RN) #2, Wound Care Nurse, confirmed Resident #87 returned from the hospital on [DATE], but he/she was not working until [DATE] and pressure ulcers were not measured and staged until his/her return to work on [DATE]. RN #2 went on to say that all wounds/pressure ulcers are measured on Thursdays. This surveyor then asked, If a resident is admitted any other day of the week other than Thursday did the wounds/pressure ulcers not get assessed, measured and staged by an RN, until the wound nurse returns to work and he/she stated, yes. During an interview on [DATE] at approximately 4:45 PM the Director of Nursing, (DON) verified Resident #87 returned for the hospital on [DATE] and the pressure ulcers were not measured and staged by the wound nurse until [DATE]. This surveyor asked if the DON would expect a newly admitted resident with wounds/pressure ulcers to be assessed, measured and staged in a timely manner and he/she stated, I think it is best if only one nurse measures and stages the wounds/pressure ulcers. The wound nurse will measure the wounds/pressure ulcers when he/she returns to work. The facility admitted Resident #95 with [DIAGNOSES REDACTED]. Record review at 12:54 PM on [DATE] revealed that the [DATE] Admission Assessment noted open areas present on the sacrum, buttocks, and toe. The [DATE] Body Audit Form noted Pressure ulcer to sacrum + L(eft) buttock and R(ight) great toe amputation (with) scab @ surgical site. No measurements or staging of the wounds were recorded until [DATE], 3 days later. Further review revealed weekly wound assessments were not completed. On [DATE] at 5:06 PM, review of Wound Observation and Assessment forms revealed that on [DATE], the pressure ulcer on the left buttock was noted as a Stage 2 measuring 4 centimeters (cm) length x 2.5 cm width x 0.1 cm depth with 100% granulation tissue and light serosanguinous-sanguinous drainage. Surrounding skin showed maceration, [DIAGNOSES REDACTED], and unexplained other. The pressure ulcer on the sacrum was noted as a Stage 4 measuring 6 cm length x 5.8 cm width x 2.6 cm depth with tunneling from ,[DATE] at 4 cm and a moderate amount of serosanguinous drainage. Surrounding skin showed maceration, [DIAGNOSES REDACTED], and unexplained other. These were the only recorded wound assessments in the record until the resident expired on [DATE]. On [DATE] at 1:45 PM, Licensed Practical Nurse (LPN) #2 provided additional information from a [DATE] wound care center appointment which noted that the sacral pressure ulcer measurements were 9 cm length x 11 cm width x 3.3 cm depth, with an area of 99 sq (square) cm and a volume of 326.7 cubic cm. Muscle and bone are exposed. Undermining has been noted at 9:00 and ends at 3:00 with a maximum distance of 4.7 cm .large amount of serosanguinous drainage .yellow slough, ,[DATE]% bright red granulation .Right Great Toe is an Unstageable Pressure Injury. Obscure full thickness skin and tissue loss Pressure Ulcer .Wound bed is ,[DATE]% dry, black eschar .Left Medial Buttock is a Stage 3 Pressure Injury Pressure Ulcer .measurements are 3.5 cm length x 2.5 cm width x 0.1 cm depth .scant amount of yellow drainage .Wound bed is ,[DATE]% granulation . Based on this information, compared to the [DATE] assessment/measurements, the sacral wound increased in size, depth, tunneling, and amount of drainage. There was little change in the buttock ulcer size, but it worsened to a Stage 3. The [DATE] wound center noted an unstageable area to the great toe (in addition to the surgical/amputation site) that the facility failed to identify and measure. During an interview on [DATE] at 1:24 PM, the Minimum Data Set (MDS) Coordinator stated that the resident's admitted was on a Friday. The Director of Nurses stated it was the practice of the facility to measure pressure ulcers on Mondays when the admission was on Friday. LPN #2 confirmed that the only weekly measurements/staging were those noted on [DATE]. Record review on [DATE] at 2:09 PM revealed Physician order [REDACTED]. Pat dry. Apply Chlorpactin 4 gm (grams). Cover (with) dry dsg (dressing) tid (three times daily) + PRN (as needed). (2) Clean L(eft) buttock (with) NS. Pat dry. Apply Chlorpactin 4 gm. Cover (with) dry dsg tid + PRN. (3) Skin Prep to R(ight) great toe amputation daily. Review of the ,[DATE] Treatment Administration Record on [DATE] at 5:00 PM revealed treatments were not done as ordered. The sacral and left buttock wound treatments were not initialed as completed 15 times from ,[DATE] through [DATE]. During an interview on [DATE] at 1:28 PM, when advised of the omissions, the Director of Nurses (DON) stated s/he expected physician's orders [REDACTED]. Review of Nurse's Notes on [DATE] at 4:14 PM revealed that the resident developed a new Stage 2 pressure ulcer on the left upper buttock on [DATE]. Review of the [DATE] Admission MDS on [DATE] at 1:05 PM revealed that the resident was coded as having one Stage 2 and one Stage 4 pressure ulcer. Measurements reflected those taken in the facility on [DATE] as opposed to those provided by the wound center on [DATE]. During an interview on [DATE] at 2:08 PM, the MDS Coordinator reviewed the [DATE] wound center report and verified s/he should have coded a Stage 3 and a Stage 4 instead of a Stage 2 and a Stage 4 as per the report confirmed as received on [DATE]. Care Plan review at 1:09 PM on [DATE] revealed that only the Activities Director and MDS Coordinator participated in the [DATE] Care Plan Conference Meeting. There was no evidence of participation by Social Services, Dietary, or the Certified Nursing Assistant. Problems included a Stage 2 pressure ulcer on the left buttock and a Stage 4 on the sacrum. During an interview at 1:11 PM on [DATE], the DON stated that an X on the form initially indicated that the staff member attended the meeting. Then, the policy changed to indicate completion of the assigned sections of the MDS and staff had to physically sign the form to indicate care plan meeting participation. The DON reviewed the Care Plan form and confirmed that only the MDS Coordinator and Activities participated. | 2020-09-01 |