cms_AK: 28
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 28 | KETCHIKAN MED CTR NEW HORIZONS TRANSITIONAL CARE | 25010 | 3100 TONGASS AVENUE | KETCHIKAN | AK | 99901 | 2019-08-23 | 686 | D | 1 | 1 | 0OWF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview the facility failed to ensure one resident #2 (out of 4 residents) reviewed for pressure injuries, did not develop an avoidable stage 2 pressure injury(partial thickness skin loss with exposed dermis (second layer of skin)presenting as a shallow open ulcer) . This failed practice caused the resident unnecessary pain, an increased risk for infection, and the potential for poor medical outcome. Findings: Pressure injury According to the National Pressure Ulcer Advisory Panel, accessed 9/7/19 at www.nouap.org A pressure injury is localized damage to the skin and/or 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. Record review from 8/20-23/19 revealed Resident # 2 was admitted to facility with [DIAGNOSES REDACTED]. a clot of blood), and [MEDICAL CONDITION]. Review of the most recent Minimum Data Set (MDS-a federally mandated assessment) a quarterly assessment dated [DATE] revealed the Resident had no pressure injuries. Further review of the MDS revealed Resident #2 was non-ambulatory, totally dependent on staff for bed movement, locomotion in the wheelchair, bathing, and needing extensive assistance (requiring two personal physical assistance) for dressing, toileting, transfers, and personal hygiene. Review of Resident #2's care plan Problem: Additional Communication Problem .Start: 9/07/18 Description: (Resident) is non-verbal, unable to speak .Problem: Requires extensive assistance/dependent with mobility and ADL's (activities of daily living) .Goal: Resident will receive max (maximum) assistance with mobility and ADL's .Start 3/23/17 Expected End: 8/31/19 . Intervention: Provide total assist with dressing .Start: 3/23/17 Description: 2 person assist . Further review of the care plan revealed no documentation of Resident # 2 pressure injury of the right great toe or how to care for the Resident with this. Record review of Wound Assessment: Pressure injury Date: 06/24/19 Location: Right great toe . site Distal right great toe .Length 0.8 cm Width 0.9 cm Depth 0cm . Treatment/dressing: Open to air Dressing type: Open to air. Wound noted during skin assessment. Appears to have been caused by shoes that resident was wearing prior to bath. Shoes have been removed from the room. Staff is educated to keep pressure off the toe and not to put shoes on resident at this time. Record review of Nursing Note (NN) dated 6/24/19 at 3:15 pm, revealed On bath day skin assessment, writer noticed a red, non-blanchable area on distal portion of right great toe. Charge nurse to bedside to assess. Appears to be pressure related injury. Record review of a NN dated 6/25/19 at 11:30 am, revealed Provider made aware of new pressure injury with no new orders noted at this time. Resident's daughter made aware of injury as well as plan to use socks instead of shoes to prevent further pressure. During an interview 8/21/19 at 10:24 am, with Licensed Nurse (LN) #4 stated they (the facility) was not able to determine how long Resident # 2 had been wearing the shoes of another resident. The other resident whom was Resident # 2 former roommate (whom passed away 3/27/19). The skin injury on the right great toe tip was noticed on the Residents bath day 6/24/19 by the Certified Nurse Assistants (CNAs) who reported to LN #4. LN #4 assessed the wound, documented with pictures, and received orders from the provider for the wound team to treat the skin injury. During an interview on 8/22/19 at 2:06 pm, with the MDS Coordinator (MDSC), when asked if Resident #2's care plan contained information on the pressure injury and how to care for the Resident, the MDSC stated the care plan did not have the information in it and he/she would expect it to be in the care plan. | 2020-09-01 |