cms_WV: 11524
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 11524 | HEARTLAND OF KEYSER | 515122 | 135 SOUTHERN DRIVE | KEYSER | WV | 26726 | 2010-09-03 | 314 | G | GVP311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, review of hospital records, staff interview, family interview, and interview with a hospital social worker, the facility failed, for one (1) of ten (10) sampled residents, to ensure a resident who entered the facility with pressure sores received necessary treatment and services to promote healing and prevent infection. Resident #115 entered the facility on 07/14/10 with a Stage III pressure sore on her coccyx and Stage I pressure sores on her right hip and left heel. From 07/28/10 to 08/04/10, the wound on the resident's coccyx significantly increased in size and developed necrotic tissue and slough which prevented staging of the wound; the staff did not notify either the resident's responsible party or attending physician of the worsening of this wound. Upon the resident arrival at the hospital (after being transferred at the insistence of the resident's responsible party on 08/07/10), the wound was "large and foul-smelling" and the odor was "overpowering"; prior to her transfer, the facility's documentation of this wound made no mention of any odor or signs / symptoms of infection. The resident was subsequently treated with intravenous antibiotics and the wound received surgical debridement. Facility census: 114. Findings include: a) Resident #115 1. Record review revealed this [AGE] year old female was admitted to the nursing facility on 07/14/10 following a hospital stay. Prior to this hospitalization , she had been living at the home of her caregiver and medical power of attorney representative (MPOA). According to the hospital history and physical examination was brought to the ER (emergency room ) following (sic) history of generalized weakness, lethargy, not eating or drinking, oliguric (low urine output) with dark foul-smelling urine. In theER on workup, patient was noticed to be dehydrated. Patient was also noticed to have urinary tract infection. Patient was advised (sic) hospitalization for further workup and management of urosepsis and dehydration. ..." According to a Transfer Summary Report hemodynamically stable" and received [MEDICATION NAME] mg every twelve (12) hours to treat the UTI, and her discharge medications [MEDICATION NAME] twice daily for five (5) more days. Her list of final [DIAGNOSES REDACTED]. - 2. Review of Resident #115's admission orders [REDACTED]. Also present on her chart was a physician orders [REDACTED]. In Section B, the MPOA indicated that, if the resident has a pulse and/or is breathing, staff was to provide limited addition interventions, to include the use of medical treatment, IV fluids and cardiac monitoring as indicated; the resident's MPOA did not select "comfort measures". In Section D, the MPOA specifically indicated the resident was not to receive a feeding tube; while the MPOA did not indicate a preference with respect to the IV fluids, there was no specific prohibition against the administration of IV fluids. - 3. The nursing admission evaluation, dated 07/14/10, identified the resident was admitted with a Stage II pressure sore on the coccyx area measuring 5 cm x 4 cm x 0.2 cm, a Stage I pressure sore on the right hip measuring 2 cm x 2 cm, and a Stage I pressure sore on the left heel measuring 5 cm x 6 cm. On 07/14/10, the physician ordered the following treatment to the Stage III pressure sore on the coccyx: "Stage III coccyx: Cleanse q3d (every three days) /c (with NSS (normal sterile saline). Apply [MEDICATION NAME] Aq. Cover /c [MEDICATION NAME] dsg (dressing)." On 07/15/10, the order was changed to: "Cleanse area /c NSS. Apply [MEDICATION NAME] (white). Cover /c [MEDICATION NAME]. Change dressing Q3D (every three days) & PRN (as needed)." A review of the resident's comprehensive care plan, with an initiated date of 07/15/10, revealed the following problem statement: "Stage I on right hip, left heel and stage (sic) III on coccyx related to recent hospitalization secondary to refusing to eat, drink, diabetes, mobility, contractures, impaired mobility (sic), incontinence." The goal associated with this problem statement was: "Skin will heal within the limits of the disease process." Interventions intended to assist the resident in achieving this goal included: " ... Evaluate and record wound status per facility guidelines until healed. ... Monitor for and report any evidence of infection such as purulent drainage, swelling, localized heat, increased pain, etc. Notify family / responsible party of skin condition. ..." - 4. A late entry in the skin progress notes, dated 07/15/10 (for 07/14/10), stated, "Res (resident) admitted on [DATE] /c (with) diagnosis (sic) of UTI, [MEDICAL CONDITION], dementia,[MEDICAL CONDITIONS], TIA ([MEDICAL CONDITION]), contractures of upper & lower extremities. She had a Braden (scale) of 9 on admit (sic) very high risk for skin breakdown. Also not eating / drinking at hospital. She was admitted /c a Stage I on Right hip 2 x 2 red area, not open, PUSH = 6. Stage III on coccyx - 5 x 4 x 0.2 20% slough /c 80% granulation, no odor, no drainage, no swelling, no c/o (complaints of) pain /c tx (treatment). PUSH score = 12, also has a Stage I on left heel 5 x 6 , PUSH score = 10. Tx order. ... Enc (encourage) to eat & drink. ..." A skin progress note, dated 07/21/10, stated, "Wound rounds completed. DCD (director of care delivery) & wound nurse on rounds. (R) (right) hip 1 x 0.2 PUSH = 3 Stage I - coccyx 0.8 x 3.0 x 0.2 D (depth) PUSH = 8 Stage III - (LE) (left) heel 4 x 6 PUSH = 9 Stage I. Coccyx - 75% slough / 25% granulation, 0 (no) odor, 0 drainage, 0 swelling, 0 s/s (signs / symptoms) infection - tolerated tx well. ..." A skin progress note, dated 07/29/10, stated, "Wound rounds completed. Late entry (for 07/28/10). DCD ' s, DON (director of nursing), wound nurse, dietary, therapy present. (R) hip - 0.8 x 0.5 Stage I PUSH = 2, (L) heel - 3.0 x 5.0 Stage I PUSH = 9, coccyx - 2.8 x 0.7 x 0.3 Stage II PUSH = 7, 10% slough 90% granulation, 0 odor, 0 drainage, 0 s/s inf (infection) 0 s/s pain. ... Cont /c ordered tx." A skin progress note, dated 08/04/10, stated, "Wound rounds completed. DON, DCD ' s, wound nurse & therapy present. (R) hip 1.4 x 1.0 Stage = I PUSH = 5. (L) HEEL 2.0 x 3.0 Stage = I PUSH = 7. Coccyx 7.0 x 7.0 x 0.8 unstageable PUSH = 14 50% necrotic tissue, 25% slough, 25% granulation. 0 odor, 0 drainage, 0 s/s inf. 0 s/s pain. ... Cont /c ordered tx." From 07/28/10 to 08/04/10, the pressure sore on Resident #115's coccyx increased in size and was no longer able to be visualized for staging due to the presence of necrotic tissue, although the wound care nurse documented there was no odor, drainage, or signs / symptoms of infection. The Stage I pressure sores or the resident's right hip and left heel did not open or change during this time. - 5. A review of the nursing notes, from 07/15/10 until 08/07/10, did not contain any assessment of the resident's pressure sores or documentation to reflect identification of any odor or other signs / symptoms of infection in the pressure sore on the resident's coccyx. - 6. On 08/07/10, the facility transferred Resident #115 to the hospital at the request of the resident's MPOA due to a change in the resident's mental status. - 7. According to the hospital history and physical examination ... (Resident #115) was brought to the emergency room with (sic) chief complaint of progressively worsening mental changes with generalized weakness and lethargy. Also patient has stopped eating and drinking for the last four days or more. ... Patient was advised (sic) hospitalization [MEDICAL CONDITION]; possible source is urinary tract infection and necrotic decubitus ulcer with severe dehydration. ... Patient was recently in (name of hospital) in July 2010 for similar urinary tract infection and dehydration, patient was treated, improved and was admitted to the nursing home following her last hospitalization . ..." Under "Clinical Assessment" was noted: "1.[MEDICAL CONDITION] secondary to urinary tract infection. 2. Necrotic sacral decubitus ulcer. 3. Severe dehydration. ..." Under "Plan" was noted: "Is to admit the patient, we will give her IV antibiotics and IV fluids. ..." A review of the hospital's discharge summary, dated 08/19/10, found: "(Resident #115) is an eighty-five year old Caucasian female, a nursing home resident who was hosptalized on [DATE] following history of unresponsiveness associated with generalized weakness, lethargy. On admission, patient was in septic shock. Patient was severely dehydrated ... Patient was hypotensive. Patient was started on IV fluids and was hospitalized for [REDACTED]. ... Clinical Assessment: 1. Infected decubitus ulcer. 2. Urinary tract infection - resolved. 3. [MEDICAL CONDITION]. ... Hospital Course: Patient was given normal saline, IV fluid challenge, followed by 150 cc per hour of IV fluids. ..." A hospital follow-up note, dated 08/26/10, stated: " This patient had a large decubit that was debrided and getting wound VAC (vacuum-assisted closure) treatment. The final hospital [DIAGNOSES REDACTED]. E-coli urosepsis. (Escherichia coli are bacteria found in feces.) 2. Infected necrotic sacral decubitus ulcer with staph infection. 3. Septic ulcer disease with GI (gastrointestinal) bleed and [MEDICAL CONDITION]. 4. Acute or [MEDICAL CONDITION]. ..." - 8. An interview with a registered nurse (RN) supervisor (Employee #70), on 09/03/10 at 10:00 a.m., revealed the MPOA wanted Resident #115 to be sent to the hospital on [DATE]. Employee #70 stated, "I offered to call the physician and obtain blood work to determine what was wrong with the resident, and the MPOA stated she wanted the resident sent to the hospital immediately. I called the physician and sent the resident to the hospital." - 9. An interview with the wound care nurse, a registered nurse (RN - Employee #61), on 09/02/10 at 1:35 p.m., revealed, when the pressure sore on Resident #115's coccyx was assessed to have increased in size on 08/04/10 and was not able to be visualized for staging due to the presence of necrotic tissue, she did not call the physician. She further stated she was new to the position and relied on some of the other nursing staff to tell her what she needed to do concerning the pressure sores. She also stated that, now, if a resident's pressure sore changed as Resident #115's did, she would call the physician immediately and schedule the resident with the wound clinic. She stated she works during the week and, after she leaves the facility each day, the floor nurses are responsible for the treatments. The floor nurses are also responsible for the treatments on the weekends. - 10. An interview with the social worker at the hospital, on 09/03/10 at 9:00 a.m., revealed that, when the resident was brought to the hospital on [DATE], the hospital social worker went into the emergency room . She stated, "The odor from the pressure sore was overpowering. I could not stand the smell. The emergency room nurses took pictures of the pressure sore on the resident's coccyx. It was large and foul smelling." She further stated, "I did the POST form on her last admission to the hospital in July 2010, and the MPOA did not want a feeding tube inserted but wanted antibiotics and IV fluids if needed. There was never any mention by the MPOA of not wanting IV fluids." - 11. In a telephone interview on 08/30/10 at 8:45 p.m., Resident #115's MPOA revealed that, although she did not a feeding tube inserted, she did want to resident to receive antibiotics and IV fluids if necessary. - 12. The resident was admitted to the nursing home on 07/14/10, with a Stage III pressure sore on the coccyx. On 08/04/10, the pressure sore became larger in size and was no longer able to be visualized for staging due to the presence of necrotic tissue; neither the resident's MPOA nor the attending physician was notified of the deterioration in the status of this pressure sore. (See citation at F157.) On 08/07/10, the resident's MPOA asked that the resident be sent to the hospital. Upon arriving at the hospital, the pressure sore was found to be overwhelmingly malodorous and severely infected; however, the nursing notes in the resident's medical record at the nursing facility failed to identify the presence of any odor or signs / symptoms of infection prior to her transfer to the hospital. During the resident's second hospital stay, she required treatment with intravenous antibiotics related to the infected wound, and the wound subsequently received surgical debridement. . | 2014-01-01 |