| 537 |
MERCER NURSING AND REHABILITATION CENTER |
515052 |
1275 SOUTHVIEW DRIVE |
BLUEFIELD |
WV |
24701 |
2018-11-29 |
684 |
E |
0 |
1 |
J9FW11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, observation, resident interview, and the National Pressure Ulcer Advisory Panel's (NPUAP), the facility failed to provide quality treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' preferences, goals for care and professional standards of practice that will meet each resident's physical, mental, and psychosocial needs. This was true for six (6) of twenty-three (23) residents reviewed. For Residents #37, #14, #345, and #9 had wounds not assess, monitor and treat wounds as indicated. Resident #43 did not have a follow appointment as directed by the discharging physician. Additionally, Resident #59's bowel and bladder incontinence was not accurately assessed. Resident identifiers: #37, #14, #345, #9, #43, and #59. Facility census: 97. Findings include: a) Resident #37 Medical record review found Resident #37 was admitted to the facility on [DATE]. Additionally, Resident #37 had a facility acquired pressure ulcer to the Matrix. Review of Resident #37 nursing assessment and wound assessments: Nursing assessments for 01/09/18, 04/10/18, and 04/10/18- No pressure ulcers noted. --10/02/18- Initial wound assessment dated [DATE]: coccyx- Stage II- measured 0.9 centimeter (cm) in length (l) and 0.6 cm in width (w) and 0.1 cm depth (d). --10/05/18 - Nursing assessment- Coccyx- dressing intact, see detailed initial pressure ulcer assessment (dated 10/02/18). Right inner foot - see detailed non-pressure wound evaluation. (None could be found). --10/08/18- Coccyx- Stage II- measured 0.8 cm l and 0.4 cm w. and 0.1 cm in depth. --10/09/18-Initial assessment-right inner heel- Stage II- blister which had ruptured and measured 3.0 cm in l and 3.5 cm in w and 0.1 cm in d. --10/17/18- coccyx- stage II- measured 0.4 cm l and 0.1 cm w. and 0.1 cm in depth right heel Stage II- measured 2.2 cm l and 3.0 cm w. and 0.1 cm in depth --10/24/18- coccyx- stage II- measured 0.4 cm l and 0.1 cm w. and 0.1 cm in depth right heel- Unstageable- measured 1.0 cm l and 1.5 cm w. and unknown depth-area with da ark red scab surrounding area red and blanches --10/31/18- coccyx- stage II- area closed right heel Unstageable- area with dark red scab surrounding area red and blanches. measured 1.0 cm l and 1.5 cm w. and depth unknown. --11/05/18- Initial Assessment- left trochanter (hip) Suspected deep tissue injury 1.5 cm in length and 1.5 cm width and unknown depth. Wound bed is dark purple in color --11/07/18- coccyx stage II- area closed for 2 weeks however surrounding skin is dark red and does not blanche. right inner heel Unstageable- area with dark red scab surrounding area red and blanches left trochanter (hip) Suspected deep tissue injury 1.5 cm in length and width and unknown depth. Wound bed is dark purple in color --11/14/18- right inner heel Unstageable- area with dark red scab surrounding area red and blanches measured 2.0 cm l and 2.0 cm w. and unknown in depth. --11/15/18- coccyx- stage II- area closed no redness noted. left trochanter (hip) - area closed red but blanches. --11/21/18- coccyx Suspected deep tissue injury- area 8 cm in length and 6 cm in width and unable to determine. right inner heel Unstageable- area with dark red scab surrounding area red and blanches --11/22/18- Initial assessment: Left heel- blister measured 3 cm x 3 cm unstageable. coccyx stage II- area closed for 2 weeks however surrounding skin is dark red and does not blanche. right inner heel Unstageable- area with dark red scab surrounding area red and blanches left trochanter (hip) Suspected deep tissue injury 1.5 cm in length and 1 cm in width and unknown depth. Wound bed is dark purple in color. b) Resident #14 Review of Resident #14's medical record revealed she was admitted to the facility on [DATE]. Further review found the following nursing assessments and wound assessments found: --Initial wound assessment -07/10/18- right buttock- Stage 2- measured 1.5 cm in l and 1.0 cm w and 0.1 cm in d. Follow wound assessments: --7/17/18- right buttocks - Stage 2- measured 2.0 cm in l and 2.0 cm w and 0.1 cm in d. --7/24/18- right buttock- Stage 2- measured 2.0 cm in l and 1.4 cm w and 0.1 cm in d. --7/31/18- right buttock- Stage 2- measured 2.0 cm in l and 1.3 cm w and 0.1 cm in d. --8/7/18- right buttock- Stage 2- measured 2.8 cm in l and 1.2 cm w and 0.1 cm in d. --8/14/18- right buttock- Stage 2- measured 2.0 cm in l and 1.0 cm w and 0.1 cm in d. --8/21/18- right buttock- Stage 2- measured 2.0 cm in l and 1.2 cm w and 0.1 cm in d. --08/28/18- right/left buttocks- Stage 2- measured 13.0 cm in l and 11.0 cm w and 0.1 cm in d. Additional notes: Area has now spread to left buttock, entire area is dark red/purple, warm to touch and does not blanche. Has multiple open areas varying in sizes, complaint of itching, bowel movements are now soft and formed, allows staff to turn more frequently, fluid intake fair. Wound care provided. --8/31/18-Nursing assessment: Stage II - sacrum- measured 13.0 cm in l x 11.0 cm in w. Multiple areas draining small amount of bright red fluid draining , no odor present. Stage II observed to sacral area- skin warm dark red/purple, non-blanchable, multiple open areas, small amount of bright red drainage present. --9/4/18- right and left buttocks- Stage II- measured 10.2 cm in l and 10.5 cm in l and 0.1 cm in d. four (4) open areas remain. --09/12/18- right and left buttocks- Stage II - measured 9.6 cm in l and 9.0 cm in l and 0.1 cm in d. three (3) open areas. --09/12/18- Nursing Assessment- right buttock and left buttock- Both reads: Unable to observe due to bordered foam dressing. No drainage or odor noted. --09/18/18- #1) coccyx - Stage II Stage II- measured 3.7 cm in l and 2.5 cm in l and 0.1 cm in d. - Area was being measured as one big area, but now open in multiple areas. Scant amount of bloody drainage observed, no odor observed. #2) - right buttock- Stage II-- measured 1.0 cm in l and 0.5 cm in l and 0.1 cm in d #3) left buttock- Stage II- measured 2.0 cm in l and 0.8 cm in l and 0.1 cm in d. --9/25/18 #1- coccyx- Stage II- measured 3.7 cm in l and 2.4 cm in l and 0.1 cm in d. #2 left buttock- Stage II- measured 2.0 cm in l and 0.7 cm in l and 0.1 cm in d. #3- right buttock- Stage II- measured 0.8 cm in l and 0.5 cm in l and 0.1 cm in d. --10/02/18- #1- coccyx- Stage II- measured 3.0 cm in l and 2.4 cm in l and 0.1 cm in d. #2 left buttock- Stage II- measured 0 cm in l and 0 cm in l and 0 cm in d. #3- right buttock- Stage II- measured 0.4 cm in l and 0.4 cm in l and 0.1 cm in d. --10/09/18- #1- coccyx- Stage II- measured 3.5 cm in l and 1.5 cm in l and 0.1 cm in d. #2 left buttock- Stage II- measured 0 cm in l and 0 cm in l and 0 cm in d. #3- right buttock- Stage II- measured 0.3 cm in l and 0.3 cm in l and 0.3 cm in d. --10/16/18- #1- coccyx- Stage III- measured 3.1 cm in l and 1.5 cm in l and 0.1 cm in d. #2 - right buttock- Stage II- measured 0.5 cm in l and 0.5 cm in l and 0.1 cm in d. --10/23/18- #1- coccyx- Stage III- measured 3.5 cm in l and 1.5 cm in l and 0.1 cm in d. #2 - right buttock- Unstageable- measured 0.5 cm in l and 0.5 cm in l and unknown d. --10/31/18- #1- coccyx- Stage III- measured 3.4 cm in l and 1.3 cm in l and 0.1 cm in d. #2 - right buttock- Unstageable- measured 0.4 cm in l and 0.4 cm in l and unknown d. --11/06/18- #1- coccyx- Stage III- measured 3.0 cm in l and 1.0 cm in l and 0.1 cm in d. #2 - right buttock- Unstageable- measured 0.2 cm in l and 0.3 cm in l and unknown d. --11/13/18- #1- coccyx- Stage III- measured 3.1 cm in l and 1.0 cm in l and 0.1 cm in d. #2- right buttock- Healed. --11/27/18- #1- coccyx- Stage III- measured 2.8 cm in l and 1.0 cm in l and 0.1 cm in d. The updated staging system developed by the National Pressure Ulcer Advisory Panel (NPUAP) includes the following definitions: Pressure Injury: A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue. Stage 1 Pressure Injury: Non-blanchable [DIAGNOSES REDACTED] of intact skin Intact skin with a localized area of non-blanchable [DIAGNOSES REDACTED], which may appear differently in darkly pigmented skin. Presence of blanchable [DIAGNOSES REDACTED] or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury. Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated [MEDICAL CONDITION] (IAD), intertriginous [MEDICAL CONDITION] (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions). Stage 3 Pressure Injury: Full-thickness skin loss Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Stage 4 Pressure Injury: Full-thickness skin and tissue loss Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) on the heel or ischemic limb should not be softened or removed. Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon or purple discoloration Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or [MEDICATION NAME] separation revealing a dark wound bed or blood filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure injury (Unstageable, Stage 3 or Stage IV. Interview with the Director of Nursing (DON) and Nursing Home Administrator (NHA) on 11/28/18 at 3:30 pm confirmed the nursing assessments and the wound sheets were not consist and accurate in type of wound, staging and location. they confirmed they had identified the inconsistency. c) Resident #9 Resident #9 was interviewed on 11/26/18 at 10:52 AM. She was noted to have a 4x4 secured with tape on the front of her right lower leg. Resident #9 stated she also had an open area on the back of her right lower leg. She stated she had completed a course of antibiotics for [MEDICAL CONDITION] but continued to have weeping of fluid from her leg requiring a dressing. Review of Resident #9's medical records revealed she had a [DIAGNOSES REDACTED]. There was no documentation of the application of a dressing to Resident #9's right lower leg. There were no physician orders regarding the application of a dressing to Resident #9's right lower leg. On 11/28/18 at 1:46 PM, Resident #9 was observed in her wheelchair in the hallway outside her room. She stated she did not have a dressing on her right lower leg at that time. She stated she was waiting for a nurse to look at it because she had been having drainage from her leg. While surveyor was speaking to Resident #9, Licensed Practical Nurse (LPN) #108 took Resident #9 into her room to assess her right lower leg. LPN #108 stated Resident #9 had an open area on the back of her right lower leg. LPN #108 stated she would have the unit's Clinical Care Supervisor (CCS) assess the area. On 11/28/18 at 2:35 PM, Resident #9 was observed in the hallway in her wheelchair. She had a dressing on her right lower leg. A wound assessment written by LPN #108 11/28/18 at 2:03 PM stated, An evaluation of this patient's wound was completed by this nurse. Wound location is: Posterior RLE (right lower extremity). Interventions for treatment and healing of this wound are contained in the patient's physician orders and interdisciplinary plan of care. Monitoring and re-evaluation of this wound will be on-going. A wound evaluation- non-pressure wound assessment was completed by LPN #108 on 11/28/18 at 2:03 PM. The wound evaluation stated, Resident c/o (complained of) sock feeling wet. UCN (unit charge nurse) assessed area. RLE with weeping vascular area that measures 1.5x 1cm x less than 0.1 cm. Area is moist and pinkish white in color. Active clear drainage noted. No odor noted. Resident does have [MEDICAL CONDITION] to BLE. (Physician's name) notified. New orders to cleanse area with skin-tegrity pat dry, apply ABD (abdominal) pad and cover with kling. Resident is not a candidate for increase in diuretics due to renal function. AMA (against medical advice) on file for refusals of ace wraps to BLE (bilateral lower extremity) and is also non-compliant with that at times. Resident aware of above. A physician's order written on 11/28/18 at 2:08 PM stated, Cleanse vascular area to RLE with skin-tegrity, pat dry, apply ABD pad and cover with kling every shift for weeping vascular area. During an interview on 11/28/18 at 3:30 PM, CCS #19 stated she had no information regarding when the right lower leg dressing observed on Resident #9 on 11/26/18 had been applied or who applied the dressing. CCS #19 was unable to locate any previous documentation regarding this dressing or a prior assessment of Resident #9's right lower leg skin condition. She stated Resident #9's leg was assessed today and a wound care order was obtained from the physician. CCS #19 stated the physician would assess the resident's leg. d) Resident #43 On 09/17/18, Resident #43 was transferred to the hospital due to chest discomfort, shortness of breath, and upper extremity [MEDICAL CONDITION]. Resident #43 was discharged from the hospital on [DATE]. The discharge summary provided by the hospital to the facility gave the plan as follows (typed as written): - Discharge back to nurse or not rehab - Resume home medications - Follow up with her regular cardiologist within the next 1-2 weeks - See PCP (primary care provider) within the week - Return if worsening concerns. Review of the medical records did not show evidence Resident #43 had seen a cardiologist within one (1) to two (2) weeks of returning to the facility from the hospital on [DATE]. On 11/07/18, Resident #43 returned to the hospital due to shortness of breath. During an interview on 11/27/18 at 12:20 PM, the Director of Nursing (DoN) was asked if an appointment with Resident #43's cardiologist had been made when she returned to the facility on [DATE] as was recommended by the discharging physician. During an interview on 11/28/18 at 9:44 AM, the DoN confirmed Resident #43 did not see a cardiologist within one (1) to two (2) weeks of returning to the facility from the hospital on [DATE]. The DoN stated on 11/27/18 an appointment with a cardiologist had been made for 12/12/18. e) Resident #345 On 11/26/18 at 11:13 AM, it was noted Resident #345 had an opened wound without any dressing on the bottom of his left foot. During an interview on11/27/18 at 9:31 AM, Licensed Practical Nurse (LPN) #23 looking for current notes about wound on foot. After looking at his foot which it appeared to be dry with a thick callus, an area that appeared to have a hole estimating 3.5 centimeters (cm) by 4 cm, with a yellowish colored layer dipping down. She said that he had this on return to the facility but could not recall when that was. During an interview on 11/27/18 at 12:00 PM, asked DoN about wound care and documentation for the wound on the left foot. It was pointed out to her that the documentation was incomplete and inconsonant. She stated that she would look to see if she can more documentation. During an interview on 11/29/18 at 8:38 AM, Administrator was asked about the wound on the left foot of Resident #345. She was asked if she could follow the skin evaluations and the wound assessments? She stated she aware of the poor documentation and is working on that currently. She agreed that the documentation did not paint a clear picture of his wound and the changes concerning the wound. Review of the medical chart revealed that the Skin Evaluation dates started 1/04/18 thru 08/28/18 never had a statement about the wound on the left foot. On the Wound Assessment portion, the first time it was documented was on 04/09/18. On 05/03/18 was the first time it was documented in the Wound Document portion. On 9/13/18 was the first time any nurse had documented any measurements. Review of the Infections Nursing Notes Portion revealed an infection to the left foot on two (2) separate occasions 05/16/18 thru 05/22/18 he received an antibiotic and then again from 08/21/18/to 08/30/18. At this time on 08/21/18 a culture and sensitivity were obtained. A review of the medical records revealed the Nurses were referring to this wound an avulsion (is when skin is pulled off). The Physician who was treating the foot referred to the wound as an ulcer. The Care Plan referred to the wound as a diabetic ulcer. Resident #345 has the following medical Diagnosis: [REDACTED]. f) Resident #59 Review of the residents minimum data set (MDS), a quarterly MDS, with an assessment reference date (ARD) of 10/22/18, found the resident was coded as being occasionally incontinent of urine and frequently incontinent of bowel. Review of the last nursing assessment, dated 10/18/18, found the resident was coded as using the toilet or bedpan and having no episodes of incontinence of urine or bowel. At 9:54 AM on 11/28/18, the Registered Nurse Assessment Coordinator (RNAC) #47, said the nursing assessment was incorrect. RN #47 provided documentation from the nursing assistants to verify the MDS was correct and the nursing assessment was incorrect. RNAC #47 said the nursing assessment should have coded the resident as having episodes of incontinence of both urine and bowel. At 11:56 AM on 11/28/18, the director of nursing (DON) confirmed the nursing assessment was incorrect. On 11/28/18 at 3:18 PM, the documentation on the nursing assessment and the MDS was discussed with the administrator and the vice president of quality care, [NAME] #136. No further information was provided before the close of the survey at 12:15 PM on 11/30/18. |
2020-09-01 |