| 62 |
WILLOWBROOKE COURT AT COUNTRY HOUSE |
85003 |
4830 KENNETT PIKE |
WILMINGTON |
DE |
19807 |
2018-07-18 |
686 |
D |
0 |
1 |
9EWR11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview and review of other documentation as indicated, it was determined that for one (R29) out of 23 sampled residents, the facility failed to ensure that a resident with pressure ulcers received the necessary treatment and services, consistent with professional standards of practice. For R29, a dependent resident with pressure ulcers, the facility lacked evidence that R29 was consistently turned side to side to prevent skin breakdown and R29's scrotum pressure ulcer was incorrectly back staged from a stage 2 to a stage 1. Findings include: : The Wound Ostomy and Continence Nurses Society, W[NAME]N Society Position Statement: Pressure Ulcer Staging, Reviewed/Revised on (MONTH) 2011, stated, The staging system, as recommended by the NPUAP and W[NAME]N, does not support down-staging or reverse staging of granulating pressure ulcers. National Pressure Ulcer Advisory Panel (NPUAP), Prevention and treatment of [REDACTED].Continue to turn and reposition the individual regardless of the support surface in use .No support surface provides complete pressure relief .Repositioning the Individual with Existing Pressure Ulcers in a Chair .Minimize seating time .Consider periods of bed rest to promote ischial and sacral ulcer healing .If sitting in a chair is necessary for individuals with pressure ulcers on the sacrum/coccyx or ischial, limit sitting to three times a day in periods of 60 minutes or less. Review of R29's clinical record revealed: R29 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of R29's CNA tasks stated that R29 was to be turned and repositioned every 2 hours since admission in (MONTH) (YEAR). R29's (MONTH) (YEAR) Documentation Survey Report revealed that turning and repositioning was not documented for the following: evening shift on 5/16/18, night shift on 5/21/18, Midnight on 5/23/18, Evening shift on 5/25/18, evening shift on 5/28/18, midnight on 5/30/18, day shift after 9:06 AM on 5/30/18, and evening shift on 5/30/18. R29's 5/21/18 Admission MDS stated that R29 required extensive assistance of two people for bed mobility. R29 was documented as having no unhealed pressure ulcers and was at risk for developing pressure ulcers. The MDS stated that R29 had a pressure reducing device for his bed and chair and was on a turning and repositioning program. The care plan for R29 revealed that starting on 5/24/18, R29 had an ADL self-care performance deficit related to [MEDICAL CONDITION] and poor balance. Interventions included that R29 required extensive assistance of staff to be turned and repositioned in bed and required a stand-up lift with staff assistance of 2 for transfers. Review of R29's CNA tasks stated that R29 was to be turned and repositioned every 2 hours in (MONTH) (YEAR). R29's (MONTH) (YEAR) Documentation Survey Report revealed that turning and repositioning was not documented for the following: night shift on 6/3/18, day shift on 6/3/18, midnight on 6/6/18, Evening shift on 6/6/18, evening shift on 6/9/18, midnight on 6/11/18, night shift on 6/13/18, night shift on 6/14/18, night shift on 6/16/18, 2 PM on 6/17/18, night shift on 6/20/18, evening shift on 6/20/18, night shift on 6/22/18, day shift on 6/23/18, day shift on 6/24/18, midnight on 6/25/18, night shift on 6/27/18, evening shift on 6/27/18, night shift on 6/28/18, midnight on 6/30/18, and 2 PM on 6/30/18. An initial wound assessment from 6/4/18 revealed that R29 had a stage 2 pressure ulcer to his scrotum due to pressure from his wheelchair pommel cushion. On 6/5/18 this cushion was discontinued and a different pressure relieving device for the wheelchair was ordered. An initial wound assessment from 6/18/18 revealed that R29 had a stage 2 pressure ulcer to his sacrum. Review of R29's care plan, last updated on 6/28/18, revealed that R29 had stage 2 pressure ulcers to his scrotum and sacrum and had the potential for pressure ulcer development related to his immobility and incontinence. Review of R29's 6/30/18 30 day MDS revealed that R29 required extensive assistance of two people for bed mobility and transfers. The MDS stated that R29 now had one stage 2 pressure ulcer, a pressure reducing device to his chair and bed, and was on a turning and repositioning program. Review of R29's CNA tasks stated that R29 was to be turned and repositioned every 2 hours in (MONTH) (YEAR). R29's (MONTH) (YEAR) Documentation Survey Report revealed that turning and repositioning was not documented for the following: day shift on 7/1/18, evening shift on 7/5/18, night shift on 7/6/18, day shift on 7/6/18, night shift on 7/10/18, evening shift on 7/11/18, midnight on 7/13/18, day shift on 7/14/18, day shift on 7/15/18, and night shift on 7/17/18. Review of R29's weekly wound assessment for his stage 2 pressure ulcer to the sacrum revealed that it was closed on 7/2/18, 7/9/18, and 7/16/18. Observations of R29 on 7/11/18 at 12:15 PM, 7/12/18 10:30 AM, 7/12/18 at 3:10 PM, 7/13/18 at 11:15 AM, 7/16/18 at 10:40 AM, 7/17/18 at 2:27 PM, 7/17/18 at 4:00 PM revealed that R29 was observed in his wheelchair with a pressure relieving cushion. There were no observations on these dates of R29 laying in bed. Review of the weekly wound assessment for R29's stage 2 scrotum pressure ulcer revealed that the last assessment was completed on 7/16/18 by E3 (ADON). The documentation showed that R29's scrotum pressure ulcer was not healed and it was a stage 1. During an interview on 7/17/18 at 3:20 PM, E3 stated that R29 mostly stayed in his wheelchair and refused to get back in bed (where he was to be turned every 2 hours to prevent pressure ulcers). E3 stated that when R29 was in bed he got anxious because he felt that he was supposed to be up for work. R29's care plan lacked evidence that he refused being in bed and preferred to be up in his wheelchair. On 7/17/18 at 3:27 PM, E6 (CNA) stated during an interview that she was R29's usual CNA for evening shift and that he was always in his wheelchair, not in bed. E6 stated that R29 would tell staff when he wanted to go to bed. E6 confirmed R29 was not repositioned in the chair. On 7/18/18 at 12:53 PM, wound care was observed of R29's scrotum stage 2 pressure ulcer. During this observation, R29's sacrum pressure ulcer had reopened. E5 (LPN) notified E3 to come back to reassess the area. After wound care R29 was observed to be placed in bed on his back, where his pressure ulcer was located. During an interview on 7/18/18 at approximately 1:10 PM, E5 (LPN) stated that R29 mostly was up in a chair during the day and that he does not typically like to be in bed. E5 stated that R29 moved around in his seat in the chair himself, but he does not get repositioned from side to side. E5 stated that when in bed R29 was to be turned and repositioned every 2 hours. During an interview on 7/18/18 at approximately 2:00 PM, E3 stated that she was aware that it was not correct to back stage a pressure ulcer and it was a mistake to check that box. The facility failed to ensure that R29, a dependent resident with pressure ulcers, was consistently turned side to side to prevent skin breakdown and R29's scrotum pressure ulcer was incorrectly back staged from a stage 2 to a stage 1. Findings were reviewed with E2 (DON) and E3 (ADON) on 7/18/18 at approximately 2:00 PM. |
2020-09-01 |