cms_WV: 11429
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 11429 | BOONE HEALTH CARE CENTER | 515117 | P.O. BOX 605 | DANVILLE | WV | 25053 | 2010-11-11 | 314 | G | IP7Z11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, review of product information found on the Internet, and staff interview, the facility failed to provide care and services for one (1) of eleven (11) residents reviewed, to prevent the development of new pressure sores for a resident who entered the facility without a pressure sore. Resident #50, who was admitted to the facility on [DATE] with intact skin, was totally dependent upon staff for bed mobility and transferring, and was identified as being at high risk for developing pressure sores. The interdisciplinary team identified her risk for developing skin breakdown in her care plan dated 06/21/10, and approaches to be implemented by staff to prevent skin breakdown included conducting weekly body audits. On 08/13/10, a nursing assistant identified Resident #50 as having a "blackened area" on her left heel. Weekly body audits were not completed in accordance with her plan of care, and the presence of this skin breakdown was not identified and treated at an earlier stage. Facility census: 84. Findings include: a) Resident #50 Record review revealed this [AGE] year old female resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]., and [MEDICAL CONDITION] bladder. The resident's admission nursing assessment, dated as completed on 06/03/10, stated the resident had no skin breakdown present on admission. This document also stated the resident was totally dependent on staff for transfers and she was non-weight bearing. The resident was also incontinent of bowel and had an indwelling Foley catheter at that time (which was removed on 08/15/10). The resident's pressure ulcer risk assessment, completed on 06/03/10, rated her as "10", indicating she was at high risk for developing pressure sores. According to her comprehensive admission assessment with an assessment reference date (ARD) of 06/10/10, she was alert but not oriented, with short and long term memory problems and moderately impaired cognitive skills for daily decision making. She was totally dependent on staff for bed mobility, transfers, and toilet use, and she was to be transferred using a mechanical lift. She had no pressure sores during the assessment reference period. Review of the resident's care plan found the following problem statement with an onset date of 06/21/10: "Potential risk for skin breakdown d/t (due to) decreased physical mobility." The goal associated with this problem statement was: "Maintain intact skin integrity thru 09/21/10." Approaches to be implemented to meet this goal included: "up (sic) in geri chair as tolerated. weekly (sic) body audit. Provide diet as ordered ... Reposition resident every 2 or 3 hours and PRN (as needed). Instruct resident / family on consequences of noncompliance with therapeutic regime (sic). Cleanse perineal area with peri wash following each bowel and/or bladder episode." -- Review of the facility's incident / accident reports, on 11/09/10, found an Incident Investigation Report involving Resident #50 and dated 10:00 a.m. on 08/13/10. Under the heading "Describe Circumstances of the Incident (Be very specific):" was written, "CNA (certified nursing assistant) (initials) notified this nurse of discoloration area to Resident's (Lt) (left) heel, black in color, measures 2.5 cc diameter (sic) soft to touch. Resident has poor bed mobility. Dr. (name) in facility and aware. New order [MEDICATION NAME] apply (sic) (Lt) heel q (every) shift. Heel lift boots (sic) @ (at) all times." Under the heading "Analysis of the Incident: (apparent cause)" was written, "Poor bed mobility." Under the heading "Describe Corrective action (sic) or Protective Action Taken: (be specific)" was written: "[MEDICATION NAME] Apply (Lt) heel q shift. Heel lift boots @ all times." -- Product information for [MEDICATION NAME] (found on the Internet at http://www.udllabs.com/pdfs/[MEDICATION NAME].pdf) revealed the following "Uses" for [MEDICATION NAME]: - "Management of decubitus ulcers." - "Forms protective barrier and speeds healing by increasing capillary blood flow into the ulcerated area. " - Product information for Heelift Suspension Boots (found on the Internet at http://www.heelift.com/) revealed the following product claims: " The Heelift ? completely eliminates pressure as the heel is floated in protective space. Studies prove Heelift Suspension Boots provide a pressure-free environment to help eliminate and prevent pressure ulcers. " -- On 11/10/10 at 11:00 a.m., the facility's unit supervisor (Employee #66) was asked to provide evidence to reflect this resident received weekly body audits in an effort to avoid skin breakdown. After review of facility documents, Employee #66 was only able to produce evidence that weekly body audits were performed on Resident #50 on the following Wednesdays: 06/09/10, 06/16/10, and 07/28/10. Employee #66 confirmed there were no additional body audits for this resident. The blackened area to the heel was discovered on 08/13/10. Based on the documentation presented by Employee #66, Resident #50 did not receive weekly body audits on 08/04/10 or 08/11/10 (before the blackened heel was identified by staff). -- A facility nurse (Employee #72) was interviewed on 11/09/10. When asked how residents were evaluated for skin breakdown, this nurse stated, "We do weekly body audits." When further questioned about how an area would not be recognized until it had become black, the nurse stated, "It should have been caught before it was black." . | 2014-03-01 |