| 51 |
HANDMAKER HOME FOR THE AGING |
35016 |
2221 NORTH ROSEMONT BOULEVARD |
TUCSON |
AZ |
85712 |
2016-10-06 |
314 |
E |
0 |
1 |
VEV011 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and policy review, the facility failed to ensure that pressure ulcer care and services were consistently provided for one resident (#24). Findings include: Resident #24 was readmitted on (MONTH) 16, (YEAR), with [DIAGNOSES REDACTED]. The admission nursing evaluation dated (MONTH) 16, (YEAR), included that the resident's left heel had a round black area, which measured 4 by 4 cm (centimeters) and that it was possibly a deep tissue injury. A pressure ulcer care plan was developed on (MONTH) 16, (YEAR), and included documentation that an unstageable pressure ulcer was present on the resident's left heel. A Braden Risk assessment dated (MONTH) 16, (YEAR), identified that the resident was a high risk for the development of a pressure ulcer. The resident's score was a 12 and according to the Braden risk assessment key, a score of 10 to 12 indicated a high risk. Review of the clinical record revealed there were no specific admission treatment orders for the unstageable pressure ulcer to the resident's left heel. A history and physical dated (MONTH) 22, (YEAR), included that eschar was present on the resident's left heel. A physician's orders [REDACTED]. The (MONTH) (YEAR), TAR included the physician's orders [REDACTED]. The next pressure ulcer assessment was not completed until 13 days later on (MONTH) 29, (YEAR). The documentation included that an unstageable pressure ulcer was present on the resident's left heel, which measured 2.5 by 3 cm and to continue the skin prep every shift and prn. Review of a nurse's note dated (MONTH) 6, (YEAR), revealed the resident had an unstageable pressure ulcer to the left heel, which measured 2 x 4 cm with 100% eschar. A review of the (MONTH) (YEAR), TARs revealed that the skin prep order which was to be done every shift had been transcribed to be done nightly and prn, and not every shift as physician ordered. Further review revealed that the skin prep was only applied three times from (MONTH) 1 through 7, by the night shift. A physician's orders [REDACTED]. Another physician's orders [REDACTED]. The next pressure ulcer assessment was not completed until 21 days later on (MONTH) 19, (YEAR), which included that an unstageable pressure ulcer was present on the resident's left heel, which measured 2 by 3.5 cm with slough/eschar present. The new recommendation was to apply Santyl everyday and prn to the slough/eschar. A physician's orders [REDACTED]. The next pressure ulcer assessment was dated (MONTH) 26, (YEAR), and included that the resident had a pressure injury to the left heel, which was unstageable and measured 2.4 by 3.7 cm with slough present. The recommendation was to continue with the same treatment. On (MONTH) 26, (YEAR), another physician's orders [REDACTED]. Review of the (MONTH) (YEAR), TAR revealed there was no documented evidence that the prescribed Santyl treatment had been provided on (MONTH) 29, as scheduled. The next pressure ulcer assessment was not completed until 28 days later on (MONTH) 23, (YEAR). The documentation included that an unstageable pressure injury was present on the resident's left heel and measured 2 by 3 cm, with slough present. The recommendation was to continue with the current treatment plan. A review of the (MONTH) (YEAR), TAR revealed the transcription of the Santyl order and to apply it every two days. However, according to the (MONTH) (YEAR), TAR, the Santyl treatment had been provided daily instead of every two days as physician ordered, except on (MONTH) 11, and 29, which were blank. An interview was conducted on (MONTH) 5, (YEAR), with the DON (Director of Nursing/staff #161). She stated that she provides the monthly pressure ulcer assessments, but the nursing staff were responsible to do the required weekly skin assessments, which would include a complete evaluation of any pressure ulcers which were present. Staff #161 stated she was not aware that the weekly wound assessments had not been provided by the licensed staff. Another interview was conducted on (MONTH) 6, (YEAR), with staff #161. She stated that the (MONTH) and (MONTH) treatment orders were not always administered as physician ordered. She also stated that the TARs were suppose to be signed when the prescribed treatment was administered. A facility policy titled, Pressure Ulcer Risk Assessment included that the purpose was to provide guidelines for the assessment and identification of residents at risk of developing pressure ulcers. The policy included that pressure ulcers are a serious skin condition for the resident and to routinely assess and document the condition of the resident's skin, per the facility's wound and skin care program. Skin assessments are to be completed weekly or more frequently if indicated. Per the policy, the at risk resident needs to be identified and have interventions implemented promptly to attempt to prevent pressure ulcers. The admission evaluation helps identify those initial approaches and interventions. In addition, the policy included that the admission evaluation may identify pre-existing signs (such as a purple or very dark area that is surrounded by profound redness, [MEDICAL CONDITION], or induration) suggesting that deep tissue damage has already occurred and additional deep tissue loss may occur. This deep tissue damage could lead to the appearance of an unavoidable stage 3 or 4 pressure ulcer or progression of a stage 1 pressure ulcer to and ulcer with eschar or exudate within days of admission. The policy also included that the following should be recorded in the resident's clinical record: 5. The condition of the resident's skin 9. Observations of anything unusual exhibited by the resident. 11. Initiation of a (pressure or non-pressure) form related to the type of alteration in skin noted. |
2020-09-01 |