| 10502 |
WAR MEMORIAL HOSP, D/P |
5.1e+151 |
1 HEALTHY WAY |
BERKELEY SPRINGS |
WV |
25411 |
2011-01-06 |
314 |
G |
0 |
1 |
CROM11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed, for one (1) of seven (7) residents reviewed who entered the facility without a pressure ulcer, to provide care and services to prevent the development of a pressure ulcer. When admitted to the facility on [DATE], Resident #15 had no pressure ulcers present and no history of having had resolved pressure sores. Facility staff failed to implement measures to assure the resident maintained good nutritional status, and the resident experienced a clinically avoidable 32 pound (#) weight loss in three (3) months at the facility. Physical therapy had developed a plan for restorative nursing care, in which the resident refused to participate for two (2) months with no re-assessment by staff. Staff interview confirmed Resident #15 had sustained a significant unplanned weight loss and that the resident's refusal to participate in restorative services could have contributed to the pressure ulcer development. The resident developed two (2) Stage II pressure ulcers with no evidence to indicate this skin breakdown was clinically unavoidable. Resident identifier: #15. Facility census: 16. Findings include: a) Resident #15 When reviewed on 01/04/11, Resident #15's medical record revealed this [AGE] year old male had been admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Documentation on the resident's comprehensive assessment, completed at the time of admission on 09/27/10 at 10:45 a.m., stated (in the area of skin assessment) the resident had a lesion on left upper eyelid, a bruise on his left forearm, a brown birthmark on his posterior right leg, and a skin tear on the anterior right lower leg. This document stated the resident, at that time, had no pressure ulcers and no history of resolved pressure ulcers. An initial care plan developed on 09/28/10 identified: "Alteration in skin integrity (sic) episodes of incontinence and Hx (history) of acne / rash (sic) Currently on neck base of hair line." The goal associated with this problem stated: "Resident will have no skin breakdown through next review." The interventions to assist the resident achieving this goal were: "1) Assess skin every shift and observe for signs of reddness (sic). Charge nurse will notify physician for treatment orders. 2) Bactrim DS i (1) PO (by mouth) everyday - MPOA (medical power of attorney representative) states resident has history of pustules on face - resolved with maintenance dose of bactrim (sic). Currently has rash on neck - hair / collar line. Will observe for signs of healing or if treatment is needed. 3) Resident's functional ability to transfer and ambulate has declined over last several wks (weeks) - assist resident, but encourage functional activity, ROM (range of motion), exercise. Therapy to evaluate for restorative nursing program." - According to the resident's comprehensive care plan dated 10/11/10, the interdisciplinary team (IDT) identified the following problem: "History of acne / rash currently on neck base of hair line. At risk for skin breakdown due to decreased mobility, medication use, disease process. Fragile skin, bruises easily, Skin (sic) tear RFA (right forearm). Pressure ulcers (sic)." (Note: According to documentation in the resident's record, the resident had no pressure ulcers at this time.) The goal related to this problem statement was: "Resident will have no skin breakdown through next review." The interventions to assist the resident in achieving this goal remained essentially the same as stated in the initial care plan, with the following additions: "Braden skin assessment quarterly. Wound / pressure ucler (sic) record if indicated. RFA skin tear treatment: [MEDICATION NAME] (sic) dressing covered with opsite (sic). Change prn (as needed) discontinue when healed. Notify physician if there are signs of infection or poor healing. When sitting up, ensure that resident is sitting on foam cushion." - Documentation recorded on forms titled "Pressure Ulcer Record" described the development of a Stage II pressure ulcer to his left heel on 11/17/10 and a Stage II pressure ulcer on his right buttock on 12/12/10. - Further record review disclosed that, on 10/11/10 (the date the resident's comprehensive care plan was established), the facility received a physician's orders [REDACTED]. On 11/03/10, the facility changed the resident's diet from regular consistency foods at all meals to pureed consistency foods for lunch and dinner and regular consistency foods at breakfast. Review of the resident's nutritional assessment disclosed that, by the time the first pressure ulcer developed on the resident's left heel, the resident had already experienced an unplanned weight loss of 13# from his admitting body weight of 147#. At that time, no new nutritional interventions were implemented to promote wound healing / skin integrity. Review of the resident's vital signs and weight record revealed the following weights: - 147# on 09/27/10 - 141# on 10/01/10 - 124# on 11/04/10 - 119# on 12/02/10 - 115# on 01/04/11 This represented a loss of 32# in approximately three (3) months. After 11/02/10, there were no further entries in the record by dietary personnel until 01/04/11, when the registered dietitian noted the resident's weight loss, described meal intakes, medications, etc., and ended by saying "resident is currently not meeting care plan goal of consuming 70% of meals or maintaining his weight." The medical record revealed no evidence of interventions (after 11/03/10) related to this significant unplanned weight loss or evidence of efforts to improve the resident's nutritional status as a means of promoting wound healing. - A physical therapy daily note, dated 10/01/10, discontinued the resident from physical therapy to a restorative nursing program. The restorative nursing program plans stated: "Ambulate on level surface with CAN (sic) and no loss of balance x 50 feet with rolling walker. Appropriate use of rolling walker during stand, pivot, transfer (sic). Exercise to improve function." The care plan problem was noted to be: "Decreased posture, decreased balance, decreased functional mobility. Recent decreased function / cognition. Dx (diagnosis): [MEDICAL CONDITION]." Approaches included: "Ambulate with rolling walker 250 feet with supervision. Promote good seated / standing posture, transfer with supervision." Review of the restorative nursing and progress summary reports revealed that, after 11/07/10, the resident did not participate in the restorative program. As of 01/04/11, there had been no reassessment to determine why the resident was refusing to participate, nor was any revision made to the care plan in light of the resident's refusal of treatment. - According to a Braden assessment of the resident's risk for developing pressure sores, completed on 10/03/10, the resident scored "17", indicating he was at "mild risk" for developing a pressure sore. According to a subsequent Braden assessment, completed on 01/03/11, the resident scored "12", indicating he was now at "high risk" for developing a pressure sore. - When interviewed on 01/04/11, the unit's director of nursing (DON - Employee #14) was not aware the resident had a pressure ulcer. Employee #14 confirmed Resident #15 had sustained a significant unplanned weight loss and that the resident's refusal to participate in restorative services could have contributed to the pressure ulcer development. . |
2015-03-01 |