cms_WV: 4014
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| rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 4014 | TAYLOR HEALTH CARE CENTER | 515057 | 2 HOSPITAL PLAZA | GRAFTON | WV | 26354 | 2017-03-01 | 314 | G | 1 | 0 | WA6611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review, staff interview, and policy review, the facility failed to provide care and treatment to a resident to promote healing of existing pressure ulcers and to prevent new sores from developing. There was no system in place to ensure skin assessments were completed timely and accurately, that interventions were implemented, monitored, and revised as appropriate, and changes in condition were recognized, evaluated, and reported to the physician, and that staff were knowledgeable in identifying and caring for pressure ulcers. Resident #74 was admitted with pressure ulcers on both elbows and his history identified a recent pressure ulcer to his coccyx. Failure to provide preventative measures resulted in actual harm to the resident by the redevelopment of the sacral pressure ulcer, a deep tissue injury to the left heel, and multiple toe wounds. Additionally, during an observation of wound care for Resident #74's, the nurse did not employ appropriate infection control techniques to reduce the risk of infecting the wound. This affected one (1) of three (3) residents reviewed for pressure ulcers. Resident identifier: #74. Facility census: Findings include: a) Resident #74 1. Review of the resident's medical record at 8:12 a.m. on 02/16/17, revealed this eighty-two (82) year old resident was admitted to the facility on [DATE] from an acute care setting. The acute care discharge summary dated 12/18/16 stated the resident presented to the hospital with increased weakness, loss of appetite and weight loss, and the inability to perform his activities of daily living (ADLs). His discharge [DIAGNOSES REDACTED]. The plan of care included in the discharge summary include, Sacral decubitus ulcer, Protect skin from further breakdown and compromise, and Frequent repositioning, keep patient active, and enforce aggressive wound care. The nursing physical assessment admission note dated 12/19/16 stated Resident #74 was admitted from an acute care center with a history of increased weakness, frequent falls, loss of appetite, rhabdomyolysis (a condition in which damaged skeletal muscle tissue breaks down rapidly), failure to thrive, muscle weakness, incontinence, and a sacral pressure ulcer. The skin assessment described, Left elbow Stage II wound 3 centimeter (cm) circle with hole in middle open purple with serious serioussangus (sic) drainage noted. Right elbow 3 cm round hole 1.25 depth with brownish/tan drainage noted. Buttocks with old red scar right proximal. The resident care record assessment written at 9:57 p.m. on 12/19/16 by Nurse Aide #138 noted Resident #74 was incontinent of bowel and bladder, and required assistance with all ADLs. -- On 12/30/16 the Assistant Director of Nursing (ADON), who was also the wound care nurse, documented a wound assessment in the computerized progress notes that included, bilateral elbows were a stage 2 on admission - now are resolving and only has some redness around perimeter -- On 01/09/17 the ADON documented an assessment stating, Bilateral elbows were noted to have stage 2 pressure ulcers on admission - areas are now dry and slightly red area - continue to use skin prep bilaterally BID (twice a day) [MEDICATION NAME]. -- On 01/16/17 the ADON wrote, Right elbow - slightly pink - open area 0.50 cm round and 0.25 deep - using skin prep - added elbow protectors resident has tendency to lean to right and puts pressure on elbow - very bony all over -- The record was silent for any assessments related to the coccyx/sacral area since the resident's admission on 12/19/16, until 01/25/17. At 6:51 a.m., Nurse Aide (NA) #121 documented, When we turned resident we found he had two sores on his bottom. I reported it to the nurse -- On 01/25/17 at 2:02 p.m. the ADON wrote, A (left elbow per pressure ulcer/location unisex body form) - resolving stage 2 - 4 cm round dk (dark) purple - not open - skin prep and elbow protectors. b (right elbow per pressure ulcer/location unisex body form) resolving stage 2 - 4 cm round dk (dark) purple with open area - 0/10 deep - skin prep - elbow protectors. -- At 3:46 p.m., on 01/25/17 Registered Nurse (RN) #153 documented, Resident has 2 Stage III (3) open areas on buttocks Drsg (dressing) applied and turn resident every two hours to prevent further breakdown. -- On 01/26/17, the Director of Nursing (DON) documented the wound assessment in the section titled Pressure Ulcer Condition: Rt (right) buttocks with 2 open areas red periwound with yellow center. Lt (left) buttocks with 1 open area red periwound with pink center. Rt heel with DTI (deep tissue injury) skin intact. Rt great toe posterior (top) pinpoint open area. All areas no odor noted. Under the section titled Pressure Ulcer Stage, the DON documented: -- A - RT buttocks 0.5 x 0.25 cm Stage 2. -- B - RT buttocks 0.25 cm x -- C - LT buttocks 0.25 cm x -- RT heel - DTI 1 cm x 1 cm unstagable. -- RT Great toe pinpoint area Stage 2. Interventions included heels elevated off of the bed with bilateral heel protectors, pillow for positioning and an air mattress for the bed. Turn every two hours and staff are to notify the physician. -- On 02/06/17, the DON documented a wound assessment evaluation in the computerized records: -- A - RT (right) buttock with open area pink center no drainage, 0.25 cm x 0.25 cm x 0,25 cm Stage 2 -- B - RT buttock no open area pink in color, 0.25 circular area superficial D/I (dry and intact) pink in color Stage 2 -- C - LT buttock no open area pink in color, superficial D/I (dry and intact) pink in color Stage 2 areas with healthy tissue -- D - RT heel DTI intact area drying 1 cm x 1 cm edges intact -- [NAME] - RT great toe pinpoint scabbed area posterior UTD (unable to determine) edges intact unable to determine -- F- RT elbow -- G - LT elbow superficial area pink in color skin intact resolved Stage 2. After reviewing the resident's medical record with the ADON/wound nurse during an interview on 02/16/17 at 9:30 a.m., the ADON confirmed Resident #74 was admitted to the facility after a stay in an acute care center for treatment of [REDACTED]. She agreed the resident was at risk for skin breakdown because he was dependent on staff for all aspects of ADL care, he was incontinent of bowel and bladder, he was thin and bony, and at nutritional risk. The ADON reported he was admitted with pressure ulcers on both elbows, and his buttocks wounds were in-house acquired on 01/25/17. The ADON stated she had no education or training in wound care, nor did she have a mentor she could contact with questions. She reported the facility did not conduct any routine body audits on the residents and there are no wound rounds or scheduled rounds with the physician to evaluate the wounds and discuss treatment options. She selected wound care treatments based on past experiences at other facilities and then notified the physician. The Director of Nursing (DON) reviewed the medical record during an interview at 9:45 a.m. on 02/16/17. She acknowledged Resident #74's skin and wounds were initially assessed on admission on 12/19/16. Weekly skin assessments were not completed. No other wound assessments were documented until 01/26/17 when the wounds were discovered on his buttocks. Registered Nurse (RN) #126 was interviewed on 02/16/17 at 11:30 a.m. She reported Resident #74 was admitted on a regular mattress until he developed the pressure ulcers on his buttocks. The air mattress was started on 01/26/17. The Minimum Data Set (MDS) nurse, interviewed on 02/20/17 at 2:45 p.m., reported she completed Resident #74's Braden assessment on 12/28/16. His score was 13 indicating he was at moderate risk for developing pressure ulcers. At 9:15 a.m. on 02/21/17, the ADON was interviewed in Resident #74's room. Upon request, she pulled back the sheets and found the heel protectors were up on the resident's shins and not protecting his heels. She acknowledged there were new wounds on his toes, which were all related to the sheets on his bed. A follow up interview and observation of Resident #74's feet was conducted with the DON on 02/21/17 at 10:50 a.m. The DON confirmed the wound tracking records lacked complete and accurate documentation of the resident's wounds. Examination of his feet at that time revealed the following: -- left 2nd toe with lateral cut across the anterior aspect below the nail -- abrasion on the anterior of the left third toe -- Right great toe with large scab over bony prominence of the joint The DON reported they need to get a cradle or something to keep the sheets off of his feet. 2. The facility policy titled Preventing Pressure Ulcers included, Any resident with a Braden score of 18 or less will be considered to be at risk of developing pressure ulcers. All residents who are determined to be at risk of breakdown shall have a weekly skin assessment documented . 3. On 02/21/17 at 9:10 a.m., the Assistant Director of Nursing (ADON)/wound care nurse provided wound care to Resident #74's sacral pressure ulcers (3 small open areas). The ADON reported she had already removed the dressing and completed her wound measurements prior to this observation. The following breaches of infection control technique were observed: -- The wound was without protection and covered with a brief containing a small amount of stool near the wound's edge. This provided a potential for introduction of microorganisms into the wounds. -- The ADON placed 2 towels, 5 washcloths, a medicine cup with Dial soap, clean gloves, and a container of Oxivir TB (disinfectant) wipes on an uncovered geri-chair. The geri-chair was an unclean surface, thus contaminating the wound care supplies creating a potential for introducing microorganisms into the resident's wound. -- The ADON donned clean gloves, pulled the cubicle curtain and cleaned 3/4 of the bedside table with the Oxivir TB wipes. At this point, the nurse's gloves were considered contaminated, and to have residue from the disinfectant wipes. -- The ADON placed a bath-basin on the table, added the soap, and placed 3 washcloths on the table next to the basin. The cleanliness of the bath basin could not be assured, which again created an opportunity to introduce microorganisms into the resident's wounds. -- The nurse soaked the first washcloth and scrubbed the resident's bottom in a circular motion moving throughout the wound bed The nurse never addressed the feces other than folding the brief under when she started. This too had the potential to contaminate the wound bed. The ADON placed the first washcloth back in the water in the basin, retrieved a second cloth, and dipped it into the bath basin and padded the resident's bottom. The nurse used the third washcloth to pat the wound area. -- Skin prep was placed around the wound perimeter and a PolyMem dressing (wicks away exudate) applied. The ADON removed her gloves and exited the room to retrieve additional dressing material without washing and/or sanitizing her hands. After reviewing the wound care observations with the Director of Nursing (DON) on 02/21/17 at 10:50 a.m., the DON stated the wound care nurse should have used 4 x 4 sponges with wound cleaner. The use of a bath basin and washcloths increased the risk for infection of the wound. The DON agreed, the ADON should have pulled the curtain before applying gloves, and should have washed her hands after removing the gloves and before exiting the room. When the wound care observations were reviewed with the ADON on 02/28/17, she stated the facility did not have wound cleaner and she did not think to use 4 x 4 sponges. She acknowledged she contaminated the water by placing the soiled washcloth back in the basin and agreed using a basin and washcloths may not be the best infection control practice when performing wound care. She was unaware she had not washed her hands after removing her gloves to retrieve an additional dressing. The ADON acknowledged she had not had any former training in wound care. 4. The facility failed to ensure staff assessing wounds and providing wound care were knowledgeable about pressure ulcers and wound care. Resident #74 was admitted to the facility following care and treatment at an acute care center for generalized weakness, frequent falls, weight loss and failure to thrive. His discharge [DIAGNOSES REDACTED]. All of these factors contributed to the resident's risk of developing pressure ulcers, but the facility failed to implement preventative measures resulting in actual harm to the resident when the sacral pressure ulcer recurred, Stage III pressure ulcers developed to the resident's buttocks, a deep tissue injury developed to the resident's left heel, and pressure areas developed on the resident's toes. | 2020-03-01 |