| 25 |
PINE LODGE |
515001 |
405 STANAFORD ROAD |
BECKLEY |
WV |
25801 |
2019-06-10 |
580 |
D |
0 |
1 |
8Y4111 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, resident interview and policy review, the facility failed to promptly notify the physician when a resident experienced a change in condition. This was true of one (1) of one (1) sample residents reviewed for infections (not UTI or Respiratory). Resident (R#33) refused physician ordered wound dressing for multiple days without the physician being notified. This practice had the potential to effeect a limited number of residents. Resident identifier: R#33. Facility census: 111. Findings included: During the initial tour of the annual Long-Term Care Survey Process, on 06/03/19 at 11:15 AM, Surveyor# observed Resident (R#33) with dried crusted drainage around a small open circular wound site located on the resident's upper abdominal right side. This was identified as a concern for further investigation by Surveyor# due to the open wound drainage and not being covered with a dressing. Review of records, on 06/10/19 at 11:01 AM, revealed R#33's brief interview for mental status (BIMs) score is fourteen (14) indicating the resident is cognitively intact. Pertinent [DIAGNOSES REDACTED]. The resident was admitted to the facility after having incision and drainage (I&D) of abscesses, which developed after having lower-back spinal surgery and after having a cholecystectomy. A cholecystectomy is the surgical procedure to remove a gallbladder. After gallbladder surgery the resident had a drainage tube at the surgical site, on his right upper abdomen, to prevent the build-up of bile, blood, and/or infection. The resident developed an abscess on his right side and another incision and drainage procedure was performed and a drainage tube was again placed to facilitate healing. On 04/04/19, after the drainage tube was removed a new order was given to clean surgical incision to right side with wound cleanser, pat dry, and apply dry dressing every day. Review of the treatment administration record (TAR) revealed daily wound care treatment including a dry dressing was ordered and started on 04/04/19. The wound care and dry dressing was applied daily from 04/04/19 until 04/10/19 when it was documented refused and applied again daily on 04/11/19 until 04/14/19 when it was documented as refused. The wound care treatment and dry dressing was applied daily again on 04/15/19 until 04/18/19 when it was documented refused. The wound care treatment and dry dressing was applied on 04/19/19, 04/20/19, 04/21/19, 04/24/19, 04/27/19, and 04/28/19. On 04/22/19, 04/23/19, 04/25/19, 04/29/19, and 04/30/19 it was documented refused, and on 04/26/19 there was no documentation either way as to refusal or provision of wound care treatment and the dry dressing, the TAR entry was blank. In the month of (MONTH) 2019 the resident had twenty seven (27) opportunities to have wound care treatment and a dressing applied daily and had the ordered treatment randomly eighteen (18) times. There was no wound care treatment provided at all during the month of May. According to the TAR, R#33 refused wound care treatment and daily dressings twenty-nine (29) days in the month of May, and two (2) days there was no documentation either way as to refusal or application of wound care or the dry dressing, the TAR was blank on those two days. According to the TAR, R#33 refused treatment on (MONTH) first, second, third, and fourth; and on 06/05/19 the wound nurse obtained an order to discontinue treatment due to refusals. From the time of the order until the order was discontinued there were sixty-two (62) opportunities to provide daily wound care treatment as ordered and it was documented treatment was provided as ordered on only eighteen (18) days, and three (3) days there was no documentation either way as to refusal or provision. There was no documented evidence the physician was notified of the resident's refusals until 06/05/19, when the order was discontinued. An interview with the wound nurse, Licensed Practical Nurse (LPN#84), on 06/10/19 at 11:44 AM, revealed LPN#84 said she kept trying to get R#33 to allow her to provide the wound treatment but he always refused. LPN#84 said the resident would let her clean and measure the wound weekly but not provide treatment and place a dry dressing on it daily as it was ordered. This surveyor requested evidence or documentation showing the resident refused wound care treatment, the physician was notified about the refusals of treatment, and R#33 was provided education concerning the importance of wound care and infection control. LPN#84 asked the nurse unit manager (LPN#61), to help review R#33's medical records for any of the requested documentation, while she finished the interview with this surveyor. LPN#84 said she was aware there was still some occasional drainage from the wound site. LPN#84 agreed the physician should have been notified concerning the resident's refusal of daily wound care and dressings. LPN#84 said she thought she contacted the physician sometime during the middle of (MONTH) and told the physician about the resident's refusal of treatment, however she said she did not document the conversation as she should have. When asked what instructions the physician gave her, LPN#84 said, I was to keep encouraging the resident to allow dressing changes. LPN#84 was asked by this surveyor if any other nursing staff tried to get the resident to comply with the ordered wound care treatment, such as the Center Nurse Executive (CNE), formerly known as the Director of Nursing or the Nurse Practitioner (NP). A Nurse Practitioner works in the facility three to four days a week and was available to see the resident. The wound nurse said she did not speak with the CNE or the NP or any other staff concerning R#33's refusals of wound care treatment. LPN#84 said she did not ask anyone else to see or speak to the resident to see if they might get R#33 to comply with the wound care treatment and/or to educate the resident on the importance of proper wound care and/or to ensure the resident understood. After review of the resident's medical records the nurse unit manager (LPN#61) stated she could find no documentation concerning refusal or non-compliance with the wound care treatment. LPN#61 said there was documentation concerning refusing care and non-compliance in other areas, but nothing concerning wound care. The facility was unable to provide any documentation or evidence that patient education was provided to the resident or any documentation that showed the physician was notified of the resident's refusals of wound care treatment. On 06/10/19 at 01:10 PM, interview with the resident revealed the wound still has some occasional drainage, but not as much as it did. When asked if anyone had explained to him the importance of wound care and applying a dry dressing to cover and catch any drainage the resident stated no one at the facility had talked to him about infections or the proper way to care for the wound. R#33 said he did not want a dressing on it now. R#33 said, I had training myself and if I wanted a dressing I'd ask for it, but it doesn't need one. When asked where he had training and what kind of training he had, the resident did not answer but informed this surveyor he was done talking about it. Review of Refusal of Treatment policy, on 06/10/19 at 03:55 PM, revealed if the patient refuses treatment staff will determine what the patient is refusing and why. Staff will try to address the patient's concerns and consult his/her supervisor. Notify physician of the refusal of treatment. Staff will determine and document what the patient is refusing; assess the reasons for refusal; advise patient of consequences of refusal; and offer alternative treatments. Document discussions with the patient/health care decision maker, physician, and other involved persons. The wound nurse did not follow the facility's policy on Refusal of Treatment. Review of care plan, on 06/10/19 at 11:23 AM, revealed a focus area related to the potential for further skin breakdown due to history of abscess to right side s/p (status [REDACTED]. An intervention added to this focus area on 06/05/19 by the wound nurse LPN#84 was Resident frequently refuses to come back from room from outside smoking for treatments to be completed A revision noted to the focus area potential for further skin breakdown on 06/06/19 now includes Resident noncompliant with wound treatments at times. The care plan was not revised timely to address resident's noncompliance with wound care treatments. The care plan was not revised to reflect any interventions addressing non-compliance and refusal of care in other areas that LPN#61 confirmed was documented in the resident's medical record. An interview with the Center Nurse Executive (CNE), on 06/10/19 at 2:30 PM, confirmed staff should have notified the physician sooner than 06/05/19, more than forty days after the resident consistently refused wound care treatment. The physician should have been notified when the resident continued refusing wound care treatment, so that the physician could order an alternative treatment if they chose to. The CNE confirmed R#33's care plan should have been revised with interventions concerning refusal of treatment and non-compliance prior to 06/05/19, due to R#33 medical record revealed non-compliance and refusal of care in other areas other than wound treatment. |
2020-09-01 |