| 88 |
DESERT HAVEN CARE CENTER |
35062 |
2645 EAST THOMAS ROAD |
PHOENIX |
AZ |
85016 |
2017-02-03 |
314 |
E |
0 |
1 |
TPN311 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record reviews, staff interviews, and policy review, the facility failed to consistently and thoroughly assess pressure ulcers for three residents (#22, #45 and #89). Finding include: -Resident #45 was admitted to the facility on (MONTH) 13, (YEAR), with [DIAGNOSES REDACTED]. Review of the clinical record revealed the resident was admitted with an unstageable pressure ulcer to the left heel. The wound measured 5.9 cm x 6.3 cm, with a black wound bed, with moderate drainage and no tunneling or undermining. An admission MDS (Minimum Data Set) assessment dated (MONTH) 20, (YEAR) included the resident had a Brief Interview for Mental Status (BIMS) score of 5, which indicated the resident had severe cognitive impairment. The MDS also included that the resident was admitted with an unstageable pressure ulcer. Further review of the clinical record including the weekly wound reviews revealed the left heel pressure ulcer was assessed weekly from (MONTH) (YEAR) through (MONTH) (YEAR). A care plan dated (MONTH) (YEAR) included the resident had a pressure ulcer. An intervention included for weekly treatment documentation to include measurement of each area of skin breakdown (width, length, depth, type of tissue and exudate). According to the weekly pressure ulcer log dated (MONTH) 3, (YEAR), the left heel pressure ulcer was identified as a stage 3 and measured 4.5 cm x 4.3 cm. The next wound assessment which included measurements was not completed until (MONTH) 30, (YEAR). Per the wound note dated (MONTH) 30, the left heel measured 4.3 cm x 4.2 cm., however, there was no description of the wound bed. Continued review of the clinical record revealed the next thorough wound assessment was completed on (MONTH) 20, (YEAR). Per the Pressure Injury Log dated (MONTH) 20, the left heel wound was a stage 3 and measured 5 x 5 x 0.2 cm, and the wound bed was pink. There were no additional wound assessments which included the measurements of the pressure ulcer to the left heel, nor a description of the wound bed until (MONTH) 25. According to the Wound Weekly Observation Tool dated (MONTH) 25, (YEAR), the left heel was a stage 3 and measured 4.8 x 4.8 x 0.4 cm depth. The wound bed was described as having 50% [MEDICATION NAME] tissue and 50% slough. The wound edges were well defined and the wound was improving. A pressure ulcer treatment observation was conducted on (MONTH) 1, (YEAR) at 7:30 a.m., with the wound nurse (staff #25) present. The wound measured 4.5 x 4.4 cm, with no measurable depth. The wound edges were well approximated and the wound bed was brownish in appearance. -Resident #89 was admitted to the facility on (MONTH) 13, (YEAR), with [DIAGNOSES REDACTED]. Review of the Nursing Admission Screening assessment dated (MONTH) 13, (YEAR), revealed no documentation that the resident had a pressure ulcer to the left ankle. Review of an admission MDS assessment dated (MONTH) 20, (YEAR) revealed the resident had a BIMS score of 8, which indicated moderate cognitive impairment. The MDS also assessed the resident to have no pressure ulcers upon admission. A health status note dated (MONTH) 27, (YEAR) revealed that during a daily foot/leg assessment, the resident was noted to have an open area on the left ankle. The area was assessed by the wound nurse and identified as a stage 2 pressure ulcer. The note did not include any measurements or a description of the wound bed. A physician's orders [REDACTED]. Review of the Treatment Records revealed wound care was provided to the left ankle through (MONTH) (YEAR). Per the (MONTH) (YEAR) Treatment Record, the wound treatment to the left ankle was changed on (MONTH) 3, to three times a week. The wound care was provided through (MONTH) 13. A care plan identified that the resident was at risk for developing a pressure ulcer. A goal included that the resident would have intact skin. The care plan did not include that the resident had a pressure ulcer to the left ankle. Review of the clinical record revealed there were no thorough assessments of the left ankle wound which included measurements and a description of the wound bed from (MONTH) 27, (YEAR) through (MONTH) 15, (YEAR). Clinical record documentation revealed that on (MONTH) 13, (YEAR) orders were received to admit the resident to hospice care. The resident expired on (MONTH) 15, (YEAR). In an interview with the wound nurse (staff #25) on (MONTH) 1, (YEAR) at 11:20 a.m., she stated that during (MONTH) and (MONTH) there was no appointed wound nurse. She said that during that time, she was a floor nurse and she was responsible for administering treatment for [REDACTED]. She stated that she took over the wound nurse position in (MONTH) and the procedure now is to perform weekly assessments on wounds and document them in the electronic charting system. In an interview with the interim Director of Nursing (DON/staff #1) on (MONTH) 1, (YEAR) at 12:31 p.m., she stated that there were no wound assessments performed during the time period when there was no wound nurse. She stated that the floor nurses were responsible for administering treatments, but not doing a full wound assessment. She also stated that there were weekly wound meetings to discuss if the wounds were improving or if there were any concerns or changes, but measurements were not necessarily part of the discussion. -Resident #22 was admitted to the facility on (MONTH) 3, (YEAR), with [DIAGNOSES REDACTED]. The admission wound note dated (MONTH) 3, (YEAR) included the resident had a stage IV pressure ulcer on the sacrum. The documentation included the wound measurements and a description of the wound bed. Physician orders [REDACTED]. Review of the Braden Scale assessment dated (MONTH) 5, (YEAR) revealed the resident was at moderate risk for the development of pressure ulcers. Review of the admission MDS assessment dated (MONTH) 10, (YEAR) revealed a Brief Interview for Mental Status score of 11, which indicated that the resident had moderate cognitive impairment. The MDS also included the resident required the assistance of two persons with bed mobility and transfers, and was admitted with a stage IV pressure ulcer to the sacrum. Review of the clinical record revealed the sacrum wound was assessed on (MONTH) 10, (YEAR), per the Wound Care/Skin Integrity Evaluation. The sacral wound was identified as a full thickness, stage IV pressure ulcer. The documentation included measurements and a description of the wound bed. Further review of the clinical record revealed there were no additional assessments of the sacral wound which included measurements until (MONTH) 30. A nurse's note dated (MONTH) 30, (YEAR) documented that the measurements of the sacrum pressure ulcer, however, there was no description of the wound bed. A comprehensive care plan identified that the resident had a stage IV pressure ulcer. The goals included that the pressure ulcer would show signs of healing, there would be no signs of infection, and the skin will remain intact. Interventions included performing treatments as ordered and monitoring for effectiveness. The care plan did not address completing weekly wound assessments. Per the nurse's notes dated (MONTH) 3 and 4, (YEAR), the documentation included a description of the sacral wound bed and measurements. The next assessment of the sacral pressure ulcer was not completed until (MONTH) 16, (YEAR). A nurse's note dated (MONTH) 16, included a description of the sacral wound, however, there were no measurements of the length and width of the wound. Continued review of the clinical record revealed there were no other assessments of the sacral pressure ulcer from (MONTH) 17, through (MONTH) 30, which included the measurements and a description of the wound bed. The next thorough wound assessment was completed by the wound care physician on (MONTH) 10, (YEAR). The assessment included the resident had a stage IV pressure ulcer to the sacrum. The wound measurements and a description of the wound bed were also included. The next thorough wound assessment was done on (MONTH) 17, (YEAR) and was completed by the wound nurse. The next thorough wound assessment was completed eight days later on (MONTH) 25, (YEAR). Per the documentation, the wound was measured and included a description of the wound bed. An interview was conducted with resident #22 on (MONTH) 2, (YEAR) at 9:15 a.m. and the resident declined a wound care observation. An interview was conducted with the wound nurse (LPN/staff #25) on (MONTH) 2, (YEAR) at 9:56 a.m. She stated that she just started doing treatments in (MONTH) for this resident. She stated the wound doctor comes once a month to see the resident. Staff #25 stated that each resident should have a skin assessment on admission and for pressure ulcers, the wound assessments and documentation should be done weekly by the wound nurse, and the weekly skin assessments should be documented by the floor nurses. She stated the missing documentation for the wounds is related to the fact that they did not have a wound nurse for several months. Review of the Pressure Ulcer Risk Assessment policy revealed that nurses should conduct skin assessments at least weekly to identify changes, and document them in the resident's medical record. A policy titled, Pressure Ulcer Treatment included that the purpose was to provide guidelines for the care of existing pressure ulcers and the prevention of additional pressure ulcers. The pressure ulcer treatment program should focus on assessing the resident and the pressure ulcer. Per the policy, the following should be recorded in the medical record: all assessment data (i.e. color, size, pain, drainage etc.) when inspecting the wound. The policy did not address how often pressure ulcer assessments should be completed. |
2020-09-01 |