cms_SD: 23
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 |
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
23 | AVANTARA HURON | 435020 | 1345 MICHIGAN AVENUE SW | HURON | SD | 57350 | 2019-05-09 | 658 | D | 0 | 1 | L4FS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and protocol review, the provider failed to ensure documentation was completed for one of four sampled residents (18) who had a pressure ulcer. Findings include: 1. Review of resident 18's medical record revealed: *A telephone order dated 1/27/19 at 4:30 p.m. from a physician (name). *Order stated to apply Allevyn to opened area on the coccyx. -Change every (q) three days and as needed (PRN) until healed. *Minimum (MDS) data set [DATE] indicated a stage 2 pressure ulcer. *There had not been any: -Additional nursing progress notes regarding that pressure ulcer. -Documentation of notification to the family or physician. -Measurements of the pressure ulcer. -Weekly skin assessments. -Initial event report. *Review of a 2/12/19 at 12:40 p.m. interdisciplinary progress note revealed: *Category: Skin assessment, physician visit. -Primary care physician (name) was there for an acute visit and assess the coccyx/buttock pressure sore. -Buttock is chapped, dry peeling skin with an open area mid coccyx noted. -Allevyn dressing changed after assessment completed. Interview on 5/08/19 at 9:50 a.m. with the director of nursing (DON) regarding resident 18 revealed: *The DON confirmed the above findings. *She saw a telephone communication from the physician dated 1/27/19 that stated to change the dressing q 3 days or as needed if it came off. *Based on that information she believed the pressure ulcer to the resident's coccyx had started on that date. *She stated she did not know why there had not been: -An initial event report. -Documentation in the pressure ulcer log. -Documentation of notification to the physician. -Documentation of notification to the family. Review of the provider's revised 3/24/17 Pressure Ulcer/Skin Breakdown-Clinical Protocol revealed: *If skin breakdown or pressure ulcer was discovered, the following would be notified immediately: -Attending physician -Resident's responsible party. -Wing coordinator and/or skin team representative. *The nurse should assess and document/report the following: -Vital signs -Full assessment of the pressure sore including location, stage, length, width, depth, and presence of exudates or necrotic tissue. -Pain assessment. -Resident's age and sex. -Resident's mobility status. -Current treatments including support surfaces. -All active diagnoses. | 2020-09-01 |