cms_AZ: 71
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 71 | HAVEN OF SCOTTSDALE | 35059 | 3293 NORTH DRINKWATER BOULEVARD | SCOTTSDALE | AZ | 85251 | 2016-09-22 | 314 | D | 0 | 1 | BZVV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed clinical record review, staff interviews and policy review, the facility failed to ensure that one resident's (#136) pressure ulcer was accurately identified and documented. Findings include: Resident #136 was admitted on (MONTH) 25, (YEAR), with [DIAGNOSES REDACTED]. According to a hospital physician progress notes [REDACTED]. Review of the admission nursing evaluation dated (MONTH) 25, (YEAR) revealed the resident had a wound on the sacrum. However, there was no clinical record documentation of any description of the wound or any measurements. Review of the admission orders [REDACTED]. There were orders to apply EPC (Endothelial Progenitor Cell) to gluteal cleft/coccyx three times a day for skin impairment, however, there was no documentation that this order was clarified with the physician, in order to determine if this treatment was for the sacral pressure ulcer. An initial care plan dated (MONTH) 25, (YEAR) included that the resident had skin breakdown to the sacrum. Interventions included for weekly skin checks and to notify the charge nurse of skin issues. Review of the pressure ulcer assessment documentation dated (MONTH) 26, (YEAR), revealed the resident had a stage III pressure ulcer to the sacrum, which measured 2.1 cm x 2.0 cm x 0.2 cm. Per the documentation, the treatment included for the use of [MEDICATION NAME]. However, there were no wound treatment orders for the use of [MEDICATION NAME]. A physician's orders [REDACTED]. Review of the (MONTH) (YEAR) TAR (Treatment Administration Record) revealed the above order to the coccyx. However, there was no clinical record documentation that this order was clarified with the physician, in order to determine if the treatment order was for the sacral pressure ulcer or if it was a new wound to the coccyx which had developed. A pressure ulcer care plan dated (MONTH) 27, (YEAR) included the resident had a stage III pressure ulcer to the sacrum. Interventions included monitoring, documenting any changes in skin status and reporting to physician as needed. Review of the physician wound care notes dated (MONTH) 28, (YEAR) revealed the resident had an acute unhealed stage III pressure ulcer located on the sacrum, which measured 2.1 cm in length x 2 cm in width x 0.2 cm in depth. The plan included to cleanse the wound with NS or water, apply alginate with [MEDICATION NAME] and an island dressing, and to change the dressing every day and as needed. However, a physician's orders [REDACTED]. Further review of the (MONTH) (YEAR) TAR revealed this order was included for the coccyx. According to the weekly pressure ulcer report dated (MONTH) 29, (YEAR), the resident had a stage III pressure ulcer to the coccyx, which measured 2.1 cm x 2.0 cm x 0.2 cm. The documentation did not indicate whether this was a new pressure ulcer to the coccyx, or if it was the same wound to the sacrum which was present upon admission. Review of the Minimum Data Set (MDS) admission assessment dated (MONTH) 1, (YEAR), revealed in Section I. that the resident had a stage II pressure ulcer to the sacral area. However, in Section M. under skin conditions, the resident was assessed to have one unhealed stage III pressure ulcer that was present upon admission. The weekly pressure ulcer report dated (MONTH) 5, (YEAR) included the resident had a stage III pressure ulcer to the coccyx, which measured 2.0 cm x 2.0 cm x 0.2 cm. In an interview with a licensed practical nurse (LPN/staff #60) conducted on (MONTH) 21, (YEAR) at 11:04 a.m., she stated that wound care, treatment, measurement and documentation are done by a wound care nurse. She further stated that the floor nurses only apply barrier creams and ointments to wounds. An interview with another LPN (staff #24) was conducted on (MONTH) 21, (YEAR) at 4:48 p.m. The Director of Nursing (DON/staff #6) was also present during the interview. Staff #24 stated that she was the treatment nurse during the time when the resident was admitted and that the resident only had a stage III pressure ulcer to the coccyx. She stated that the resident did not have any pressure ulcer on the sacrum. In another interview with staff #24 on (MONTH) 22, (YEAR) at 9:00 a.m., she stated that when conducting a treatment, she documents what she sees. She said when the site of the wound is different from the physician's documentation, she will clarify it with the physician. Staff #6 was also present during the interview stated that she could not tell if the resident had two pressure ulcers, one on the sacrum and one on the coccyx, or if the physician and/or nurse just made a mistake in identifying the location of the wound. An interview with the wound care physician (staff #79) was conducted on (MONTH) 22, (YEAR) at 9:46 a.m. She stated that the resident only had one pressure ulcer and it's location and stage is whatever her documentation indicated. The policy regarding Wound Management included a comprehensive wound management program with a goal to promote the highest level of functioning and well-being of residents and to minimize the number of residents that develop in house acquired pressure ulcers. All residents with wounds receive treatment and services consistent with the resident's goals of treatment. The policy included that pressure ulcers are to be assessed weekly and that nursing staff shall describe and document a full assessment of the pressure sore, including the location, stage, length, width, depth and the presence of exudate or necrotic tissue. | 2020-09-01 |