cms_AK: 6
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 6 | KETCHIKAN MED CTR NEW HORIZONS TRANSITIONAL CARE | 25010 | 3100 TONGASS AVENUE | KETCHIKAN | AK | 99901 | 2017-05-19 | 314 | D | 0 | 1 | YBQY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, observation and policy review, the facility failed to: 1) prevent a pressure injury, and 2) follow treatment interventions for a pressure injury. Specifically, the facility failed to implement preventative measures in a timely manner and failed to provide the necessary treatment for [REDACTED].#5) out of 6 sampled residents who were identified by the facility for at risk for pressure injuries. This failed practice caused the resident to obtain an avoidable pressure injury and delayed treatment which resulted in pain with an increased risk for infection, delayed healing, and poor medical outcome. Findings: Resident #5 Record review from 5/16-18/17 revealed Resident #5 was admitted to the facility with failure to thrive, recurrent skin integrity issues, diabetes, stroke and flaccidity to left side of body. Further review revealed, the Resident had a pressure injury on the left heel on admission. Review of the admission MDS (Minimum Data Set) assessment dated [DATE] revealed the Resident was coded as: 1) Being at risk for pressure ulcers; and 2) Had an unhealed unstageable (slough/eschar) pressure ulcer on the left heel. Further review of the admission MDS revealed the Resident coded as the following under Activities of Daily Living (ADLs): 1) Extensive assist with two staff during bed mobility and transfer. 2) Supervision with locomotion on the unit; and 3) Total assistance with bathing and hygiene. Review of the medical record revealed Resident #5 had a new pressure injury to the right heel, identified on 4/27/17. The pressure injury was staged as - Unstageable .Yellow; Brown; Eschar . Review of the most recent MDS quarterly assessment, dated 5/9/17, revealed the Resident was at risk for pressure ulcers and had two unhealed pressure ulcers: an unstageable deep tissue ulcer to the left heel and a new unstageable (slough/eschar) ulcer to the right heel. Further review revealed the Resident's required assistance with Activities of Daily Living (ADLs): 1) Total assistance with two staff during bed mobility; 2) Extensive assistance with two staff during transfers; 3) Extensive assistance with one staff during locomotion on unit; 4) Extensive assist with one staff during hygiene; and 5) Total assistance with bathing. Record review of the Resident's comprehensive care plan, with various revision dates, revealed the Resident had an alteration in skin integrity with a start date of 5/3/17. Interventions included: follow treatment plan as ordered by provider, bilateral pressure relieving boots. The boots to relieve pressure were implemented after the discovery of the second pressure injury on the right heel. Avoidable pressure ulcer - right heel. Record review of a physical therapy note, dated 4/3/17, revealed Reiterated recommendations of repositioning (Resident) correctly in (wheelchair) throughout the day, angled foot rest or elevating leg rest. Review of a physical therapy note, dated 4/27/17, revealed the Resident had developed an unstageable pressure ulcer to the right heel. The note described the wound as black, eschar, fragile tan and slough. During an interview on 5/17/17 at 9:46 am Charge Nurse (CN) stated Resident #5 had an extensive history of recurrent pressure ulcers and poor sensation in the lower extremities. The CN continued to state the Resident had flaccidity to the left side and was only able to use the right side for mobility in and out of bed. The CN added, the Resident had self-propelled in a wheelchair with the right foot while wearing house shoes prior to the discovery of the pressure ulcer to the right heal. The Resident was described as using the right heel to dig on the floor to gain momentum to propel self in the wheelchair. During an interview on 5/17/17 at 10:45 am, Physical Therapist (PT) #1 stated Resident #5 currently had a pressure ulcer to the right heel. The PT further stated the wound was most likely caused by the Resident using right heal to perform bed mobility adjustments and propelling self in wheelchair. The PT stated house shoes were not an appropriate form of footwear for this resident to propel self, the house shoes could have contributed to development of the ulcer. PT #2 then joined the interview. PT #s 1 and 2 stated there were other options the facility could have tried prior to the pressure ulcer development to decrease the Resident's chance of developing an ulcer within the facility. During an interview on 5/17/17 at 12:57 am the Medical Director stated the cause of the pressure ulcer could have been associated to Resident #5 wearing house shoes while using the right heal to propel him/her self in the wheelchair. The Medical Director stated the Resident could have benefited from the use of a motorized wheelchair in efforts to relieve pressure to the right heel. The Medical Director added the facility could have placed pressure releasing boots on sooner to prevent a pressure ulcer in conjunction with the Resident's history of poor circulation and previous pressure ulcers. During an interview on 5/17/14 at 2:22 pm the MDS Coordinator stated it would have been best practice to have placed pressure relieving boots on Resident #5 since admission due to the Resident's history of recurrent pressure ulcers. Pressure Injury care Review of the Resident #5's comprehensive care plan, with various revision dates, revealed the Resident had a plan of care for alteration in skin integrity with a start date of 5/3/17. Interventions included: follow treatment plan as ordered by provider, bilateral pressure relieving boots. Record review of physical therapy note, dated 5/12/17, revealed dressing to right heel santly to wound bed on right side, not on left, covered by foam dressing cut to approximate size .[MEDICATION NAME] heavily applied to entire leg, foot and toes, [MEDICATION NAME] gauze wrap and secure with coban . During an observation on 5/16/17 at 11:18 am Resident #5 had hard-framed foam and Velcro pressure relief boots on both feet. During an observation on 5/16/17 at 12:27 pm, certified nursing assistant (CNA) #1 removed the hard-framed foam and Velcro pressure relief boot from the right foot to dress the Resident. At that time, the bandage fell off the Resident's right heal, exposing the wound to the exterior environment. When the CNA reapplied the boots, he/she gathered the excess pant material and wadded the material around the top of each boot. Random observations on 5/16/17 from 12:27 pm to 2:47 pm (2 hours) revealed the Resident's wound was still uncovered. During an interview on 5/16/17 at 2:27 pm Licensed Nurse (LN) #1 was asked by the Surveyor if the uncovered bandaged was reported by CNA #1. The LN stated he/she was unaware of the wound being uncovered until the Surveyor informed him/her. The LN further stated the wound was not to be uncovered. During the same interview the LN went to assess the Resident and noted the pants fabric rolled up on the top of each boot and stated the area was too constricted by the wadded up excess material. The LN added this was concerning because of the Resident's poor circulation. Review of the facility's policy entitled Skin Assessment and Pressure Ulcer Management, dated 5/14/15, revealed The following risk factors increase resident's risk for skin breakdown: The presence of cardiac, vascular, renal, metabolic or respiratory impairment(,) Advanced age (,) Obesity(,) Infection(,) Dementia(,) [MEDICAL CONDITION] .(,) Presence of previously healed pressure ulcer(,) .receiving .steroid therapy. NOTE: A resident with one or more of these factors should be considered at the next higher risk .Preventive measures will be utilized to decrease the risk of pressure ulcer development and improve health of existing ulcers. Existing pressure ulcers will receive appropriate therapeutic and preventive interventions. | 2020-09-01 |