cms_WV: 3811
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 3811 | PIERPONT CENTER AT FAIRMONT CAMPUS | 515155 | 1543 COUNTRY CLUB ROAD | FAIRMONT | WV | 26554 | 2017-04-21 | 280 | D | 1 | 0 | 0AC711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on staff interview, observation, and clinical record review, the facility failed to revise a resident's care plan to address assessing pain due to her pressure sores. This was found for one (1) of five (5) sampled residents with pressure sores. Resident Identifier: #21. Facility census: 97. The findings include: a) Resident #21 Clinical record review revealed Resident #21 had [DIAGNOSES REDACTED]. She was incontinent of bowel and bladder and had an unstageable pressure ulcer on her coccyx measuring 7 by 5 centimeters and a suspected deep tissue injury to right heel. On 04/19/17 at 10:10 a.m., nurse aide (NA) #39 came to the nurses' station and reported to Licensed Practical Nurse (LPN) #69 and Unit Manager (UM) #60 that Resident #21 was crying in pain whenever I touched her right foot. I think she needs something for pain. LPN #69 stated, while standing by the medication cart, I need to see if she needs Tylenol before you do the dressing change. UM #60 stated, I will check before I start, if she complains of pain, I will stop and do it later. On 04/19/17 at 10:12 a.m., UM #60 entered Resident #21's room to perform the resident's wound treatment. UM #60 touched Resident #21's right heel to apply Sureprep to the SDTI. Resident #21 closed her eyes, made a facial grimace as though in pain, open her mouth, cried out, pulled her arms to her chest, and clenched her fists. She shook her arms. UM #60 continued the treatment stating to resident, It is alright. UM #60 kept talking to resident about her family members, but continued with the treatment. UM #60 then performed the wound treatment to the unstageable coccyx wound. Resident #21 continued with facial grimacing and moaning. UM #60 then turned Resident #21 from side to side to change incontinence pad. Resident #21 cried out, grabbed at UM #60's ID badge, and pulled the badge with her closed fists. UM #60 completed the procedure at 10:30 a.m. and said to the resident, We will bring you some Tylenol now. At 10:35 a.m., UM #60 reported to LPN #69 that Resident #21 had some intermittent pain during the dressing change and, You can check to see if she needs some Tylenol. The resident's 03/30/17 care plan was revised to include the resident's actual skin breakdown. The care plan interventions included were: assist resident in turning and reposition every 2 hours, float heels while in bed, monitor skin for signs/symptoms of skin breakdown, provide pericare/incontinence care as needed, provide wound treatment as ordered, skin check per policy. The resident's care plan did not address pain management related to the pressure ulcers. During an interview on 04/19/17 at 5:39 p.m., Clinical Reimbursement Coordinator (CRC) #10 stated Resident #21's care plan for the new pressure sores should have included an assessment of the resident's pain and premedication as needed prior to performing the wound treatment. During an interview on 04/19/17 at 5:45 p.m., Director of Nursing (DON) #18 confirmed Resident #21's care plan did not contain any intervention regarding assessing the resident's pain prior to performing wound treatment. DON #18 stated an intervention should have been included on the resident's care plan. | 2020-08-01 |