| 99 |
GUAM MEMORIAL HOSPITAL AUTHORITY |
655000 |
499 NORTH SABANA DRIVE |
BARRIGADA |
GU |
96913 |
2010-09-17 |
309 |
D |
0 |
1 |
7DPX11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility did not provide the necessary care and services to enable the resident to attain or maintain the highest practicable physical well-being for three of 10 sampled residents. (Residents 3, 5, and 6). Findings include: 1. Resident 3 was admitted to the facility on [DATE] with several [DIAGNOSES REDACTED]. Review of the medical record revealed that the resident was admitted from the hospital where she was treated for [REDACTED]. The minimum data set ((MDS) dated [DATE] described the resident as having short-term memory problem, with moderately impaired cognitive skills for decision-making, and was dependent on staff for all activities of daily living (ADL). Review of the medical record revealed that Resident 3 had undergone a left arm exploration on 8/31/10 for a possible abscess and that after the procedure, the physician had made an order that no dressing on the arm was required. During skin care observation at 10:45 a.m. on 9/17/10, the left arm wound was observed uncovered but the area around it was noted to reddened and had slight swelling. Review of the medical record revealed that while a care plan was available for the prevention and treatment of [REDACTED]. In addition, there was no evidence that continuing assessments were conducted to determine progress or lack of wound healing. The treatment nurse stated that the no treatment orders were made by the physician but observed that the would indeed appeared reddened. Further review revealed that while wound assessments dated 8/15/10 and 8/24/10 noted wounds on the resident's upper buttocks, sacral area, and left hip, there was no evidence that monitoring was being conducted on [MEDICAL CONDITION] that were on the lateral aspect of the resident's lower legs to determine whether or not interventions were necessary. During the same skin care observation, both [MEDICAL CONDITION] appeared to have black eschar that were dry and intact. No measurements of the lesion were available and no mention of them were made in the nurses notes or in the wound assessment sheets. 2. Resident 5 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Occupational therapist's initial evaluation dated 8/23/10 revealed that the resident was admitted to the acute hospital on [DATE] following a month stay at the naval hospital with [DIAGNOSES REDACTED]. The resident's MDS dated [DATE] revealed the resident was awake, alert, and verbally responsive. A review of the rehab daily treatment record dated 9/1/10 revealed that a sharp debridement of the left hand wound was done by physical therapist (PT). The physical therapy summary note detail dated 9/1/10 revealed that the left hand dorsal aspect wound was covered 100% with black, thick, necrotic tissue with a length of 6.5 cm and 6 cm wide and undetermined depth. PT's treatment included removal of 100% necrotic tissue. The note further read: "Wound now covered in 90% with yellow firmly adhering tissue with mod. (moderate) purulent drainage mainly from lat. (lateral) aspect of wound." On 9/16/10 at 5:30 p.m., the resident was more alert and conversant. On the same day at 5:40 p.m., the resident's left hand dressing change was observed. Upon surveyor request, the licensed nurse measured the debrided area as 10 cm long and 10 cm wide and described the area with 85% yellow and 15% pink. The licensed nurse cleansed the debrided area in the left hand with normal saline. A wet to dry dressing was applied after the saline flush. Review of all the progress notes revealed that there was no documentation of an assessment of the necrotic area in left dorsal hand on admission (on 8/21/10) until the necrotic area was debrided by PT on 9/1/10. Thereafter, the debrided area was not thoroughly assessed until 9/16/10 when the surveyor addressed the issue with charge nurse. 3. Resident 6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 9/15/10 at 10:20 a.m., during the initial tour, the Resident 6 went out of the facility for her [MEDICAL TREATMENT] treatment in an acute hospital facility. The resident room had contact isolation precautions posted outside the door. Interview with the licensed nurse indicated that she was not sure of the cause of isolation. The licensed nurse added that the resident has either (MRSA) [MEDICAL CONDITION]-resistant staphylococcus aureus or (MDR) multi drug resistant infection from the wound in the right stump. The admission nurses notes dated 7/15/10 revealed that the "right mid-foot amputation dressing wet-dry done. Area is reddish pink with evidence of granulation. There is presence of tunneling about 1 inch on the 1700 side. No foul odor noted. Plantar surface slightly red in color." The physical therapy (PT) initial evaluation dated 7/20/10 revealed the resident was admitted to the acute hospital on [DATE] with right foot gangrene and underwent right metatarsal amputation. The main barrier to therapy was resident's "not cooperating with PT." The post amputated wound site was not always thoroughly assessed and addressed accordingly. On 7/23/10 at 22:28 the nurses notes revealed an open sore at the bottom of the right foot and when pressed, a sero-sanguinous drainage came out from the amputated site. On the same day at 04:43 wound care to the right foot was done and was noted as, "remains open and noted some necrotic tissue posterior portion of the open area and draining sore in the sole part." On 7/30/10, the wound was "Noted some sero-sanguinous drainage from the [MEDICAL CONDITION] site. Bottom sore packed with small gauze." On 8/12/10, the wound was described "with evidence of granulation but there is presence of tunneling at the 1800 site below the wound. On 8/17/10, nurses notes revealed, "2x2 wound noted at arch area, redness and swelling noted as well. Wound is also with foul odor." On 8/21/10, the wound was "with evidence of granulation on wound but still with tunneling on 1800 about ? inch deep and measures 1x1 cm on the surface with slight pus like drainage." On 8/24/10, nurses notes revealed that "Wound care done to (R ) forefoot and arch area, foul odor noted; on 9/04/10, "Right foot dressing done with [MEDICATION NAME] gel as ordered;" on 9/8/10, "Stump wound reddish in color but plantar wound with foul odor and yellowish discharge. Right heel blackish in color;" and on 9/16/10, "Open area with red wound base with granulation tissue no drainage." On 9/16/10 at 3:15 p.m. a licensed nurse was observed doing a dressing change in Resident 6's post amputated right forefoot area. The dressing removed was heavily soaked with red drainage. The licensed nurse irrigated the top beefy red area with saline and applied Hydrogel. The licensed nurse indicated that the night shift does the measurement of the wounds and pressure ulcers when they do the dressing change in their shift. However, the licensed nurse measured the tunneling on 1800 site at 2 cm deep. The nurse applied the Hydrogel and wet dressing on the top and middle tunneling open areas. A dry 4x4 gauze was applied on the necrotic bottom right heel and wrapped the foot with Kerlix. In an interview, the licensed nurse stated that the resident's physician was informed when there were changes in the post surgical wound. She also stated that the resident's white blood count remained high and the physician ordered another dose of [MEDICATION NAME]. A review of all the nurses' progress notes revealed that there was no documentation that nurses were notifying the physician when there was a change in the wound area such as increase in drainage, foul odor or the onset of the necrotic area at the bottom heel of the right foot. |
2014-12-01 |