cms_ID: 46
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 46 | WEISER CARE OF CASCADIA | 135010 | 331 EAST PARK STREET | WEISER | ID | 83672 | 2018-06-15 | 686 | G | 0 | 1 | GRQ011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and review of facility policies, resident records, and I and A Reports, it was determined the facility failed to prevent the development and worsening of a pressure ulcer. This was true for 1 of 1 sampled residents (#29) reviewed for pressure ulcers. This deficient practice caused harm to Resident #29 when she developed a blister on her coccyx (tailbone area) that deteriorated and became an unstageable pressure ulcer. Findings include: The facility's policy and procedure for Prevention and treatment of [REDACTED]. * Residents at risk for developing pressure ulcers are identified by using the Braden Scale. * Interventions for pressure ulcers and other wound and skin issues are developed by collaborating with the interdisciplinary team and are implemented to identify, prevent, or decrease the risk of developing pressure and/or non-pressure wounds. * Basic or routine care could include but was not limited to: redistribute pressure, minimize moisture contact with the skin and keep the skin clean, provide appropriate, pressure-redistributing, support surfaces, providing surfaces that are not irritating to skin, and maintain or improve nutrition and hydration status, where feasible. Resident #29 was admitted to the facility on [DATE] with multiple diagnoses, including other abnormalities of gait and mobility, and muscle wasting atrophy. Resident #29's quarterly MDS assessment, dated 4/26/18, documented she was at risk for developing pressure ulcers and no pressure ulcers were present. Resident #29's Braden Scale for Predicting Pressure Sore risk, dated 5/1/18 at 11:33 AM, documented a moderate risk for developing pressures sores. Resident #29's significant change MDS assessment, dated 5/23/18, documented she was at risk for developing pressure ulcers and had one unstageable pressure ulcer measuring 2.0 (length) by 2.0 (width) by 0.2 deep. Resident #29's physician orders [REDACTED]. Resident #29's current care plan directed staff to provide the following interventions: * Assess skin weekly and as needed, and was initiated on 7/9/14. * A pressure relieving mattress to the bed and a pressure reducing cushion to the wheelchair, and was initiated on 2/16/17. * Reposition the resident in bed during rounds and as needed, and was initiated on 2/11/15. * When out of bed, change the resident's position by toileting, uploading, shifting weight, ambulating or return to bed for rest. When in bed, turn and reposition q (every) 2 hours, and was was initiated on 7/30/15. The following interventions were initiated on 5/22/18: * Assess for pain every shift/as needed before changing the dressing, and give medication per the physician's orders [REDACTED]. * Complete the Daily Monitoring Pressure Ulcer Report. * Encourage frequent position changes every 2 hours. * Follow physician's orders [REDACTED]. * Specialty mattress-air mattress. * Resident #29 out of bed only for meals, initiated on 5/25/18. Resident #29's Weekly Skin Checks documented the following: * On 5/15/18 at 9:27 PM: No skin conditions, changes, ulcers, or injuries. * On 5/22/18 at 12:27 PM: An open wound on the coccyx with slough (yellow, devitalized tissue). * On 5/29/18 at 11:36 PM: Skin warm, dry and very fragile. Cont(inue) present treatment to wound on coccyx, dressing clean dry and intact. * On 6/6/18 at 3:17 AM: Skin warm and dry but at times moist due to incontinence. Coccyx area red . * On 6/12/18 at 11:17 PM: Skin warm, dry and very fragile. Wound on coccyx covered with dressing. Dressing clean, dry and intact. Resident #29's Weekly Skin Alteration Reports documented the following: * On 5/11/18 at 1:46 PM: A fluid-filled blister below the coccyx, circular in shape and measuring 2 cm in diameter. It was first observed on 5/11/18. * On 5/25/18 at 1:46 PM: A 2 cm by 2 cm wound on the coccyx was first observed on 5/18/18, it was healing slowly, and calcium alginate and [MEDICATION NAME] dressing were continued daily. Resident #29's Weekly Pressure Ulcer BWAT Reports documented the following: * On 5/21/18 at 10:36 AM: A new onset pressure ulcer on the coccyx, measuring 2 cm (length) by 2 cm (width) by 0.2 cm (depth) and was unstageable. The ulcer was first observed on 5/11/18 and required the following treatment: wound cleanser, skin prep to surround tissue, [MEDICATION NAME] alginate to the wound bed, and cover with a [MEDICATION NAME] foam dressing. * On 5/28/18 at 10:36 AM: The pressure wound on the coccyx measured 2 cm by 2.1 cm by 0.8 cm and was Stage 2. Wound care was updated to [MEDICATION NAME] ointment on the wound bed and cover with an Alevyn dressing. * On 5/31/18 at 1:57 PM: The pressure wound to the coccyx measured 2 cm by 1.8 cm by 0.5 cm and was Stage 2. The wound was healing nicely, bed visible, beefy red. Size decreasing . *On 6/7/18 at 1:57 PM: The pressure wound to the coccyx measured 1.2 cm by 1.6 cm by 0.4 cm and was Stage 2. The Treatment/Evaluation of Effectiveness was to continue the current plan of care. Resident #29's I and A Reports documented the following: * An I and A Investigation, dated 5/11/18, documented a small fluid-filled blister was discovered below the coccyx, the site was cleansed, and a dressing was applied. The event was described as a shear/rub causing a blister. It was recommended to use a cushioned dressing and change the dressing routinely. * On 5/21/18, a stage 3 pressure sore measuring 2 cm by 2 cm by 0.2 cm was present on the coccyx. The Pressure Ulcer Investigation documented the following: (A) clear blister on (the) coccyx (was) reported on 5/13/18, (a) foam/sponge drsg (dressing) (was) applied and staff cont(inue) turning q 2 hours. Family to come and pick up recliner. Over (the) wkend (weekend) (the) wound changed to (a) pressure wound 2 cm-2cm by 0.2 cm with off white slough across (the wound) bed. Surrounding tissue (was) intact, no adipose tissue (fat) noted between skin and bone, tissue loose and moveable. It was recommended to use a dressing, remove the recliner, use an air mattress, change the wheelchair, provide incontinence care, reposition side to side, and strongly encourage fluids. Resident #29's Progress Notes documented the following: * On 5/11/18 at 1:13 PM, a small fluid-filled blister was noted below the coccyx measuring 2 cm in diameter and was circular in shape. * On 5/11/18 at 4:53 PM, a fluid-filled blister was noted in the coccyx area, and it appeared to be caused by the incontinence brief pinching the tissue. The area was cleansed and a [MEDICATION NAME] dressing was applied. The wound measured 2.1 cm by 1.8 cm. * On 5/14/18 at 8:47 AM, the fluid-filled blister remained and was discussed by the event committee. The area was cleansed and a cushioned dressing was applied. Will continue to monitor and change dressing via altered skin evaluations. Nurse supervisor to do this. * On 5/15/18 at 1:30 PM, A blister was present on the buttock area and it measured 1.2 cm by 1 cm. The site was cleansed and a foam dressing was applied. An order was requested for physical therapy because the resident was no longer bearing weight during transfers. She required one person assistance to transfer a month prior. * On 5/16/18 at 7:17 PM, the physician was notified regarding the blister on the buttocks and continued care with a cushioned dressing. The nurse supervisor was to change the dressing. * On 5/21/18 at 1:36 PM, staff reported a change in the coccyx wound over the weekend. The wound depth had increased to 0.2 cm and it was 2 cm in length. The wound bed was filled with slough except for a small area at the base of the wound. The wound was round, crater-like with definite edges, no undermining. Wound care was provided including wound cleanser, skin prep to the surrounding intact tissue, [MEDICATION NAME] Alginate to the wound bed, and a [MEDICATION NAME] sponge dressing was applied to cover the wound. Will inform Dr (doctor) of change. * On 5/22/18 at 9:20 AM, the event committee discussed the blister to the coccyx that was noted on 5/11/18 and a foam dressing was applied. The area was now an unstageable pressure ulcer. The family was to remove the resident's recliner from her room, treatments were in place for wound care, and an air mattress was to be applied to the bed. The dietician was to review nutritional interventions and the wheelchair cushion was changed. The care plan was updated and physician were to be notified. * On 5/22/18 at 5:15 PM, the slough was separating from the wound bed on the right side, pink tissue was visible underneath, and the wound measured 2 cm by 2 cm and was a Stage 2 pressure wound. * On 5/28/18 at 10:36 AM, the pressure ulcer on the coccyx measured 2 cm by 2.1 cm by 0.8 cm and was Stage 2. The dressing was updated to [MEDICATION NAME] ointment on the wound bed and Alevyn dressing to cover the wound. * On 5/30/18 at 1:32 PM, the resident cried out quite often, ate poorly, and was medicated with [MEDICATION NAME] (narcotic pain medication) twice for pain. The dressing was changed on the coccyx by the nurse supervisor. * On 5/31/18 at 1:57 PM, the pressure ulcer to the coccyx measured 2 cm by 1.8 cm by 0.5 cm. The wound was healing nicely, the wound bed was visible and beefy red. * On 6/1/18 at 12:44 PM, a new order was received for a [MEDICATION NAME] (narcotic pain medication) patch 25 mcg. * On 6/1/18 at 2:24 PM, the wound dressing was changed, the wound was red and beefy, the edge of the wound was pink, and the wound bed measured .02 deep. * On 6/4/18 at 4:03 PM, the pressure ulcer continued to improve with [MEDICATION NAME] and an Alevyn dressing, and it measured 1.8 cm by 1.4 cm by 0.6 cm. * On 6/6/18 at 10:24 AM, the wound dressing regimen was changed to include Alginate to a small area on the right side of the wound bed due to slough, and the wound measured 1.7 by 1.8 by 0.4 cm. * On 6/6/18 at 11:06 AM, there was a care plan conference that discussed the resident was declining, now required total assistance for cares, exhibited worrying, nervousness, and yelling, and increased antidepressant medication in May. A medication patch was ordered for pain management. Resident #29's family member believed she was trying to pass away. She lost 6.2 pounds in a month, oral intake was refused to 25%, and nutrition interventions were in place. Other than getting up for meals, Resident #29 was on bed rest and the coccyx wound was being monitored for healing. * On 6/7/18 at 1:57 PM, the coccyx wound measured 1.2 cm by 1.6 cm by 0.4 cm and was Stage 2. * On 6/10/18 at 11:08 AM, the dressing was changed to the coccyx and the area was red with signs of healing. [MEDICATION NAME] was applied to the wound and an Alevyn dressing was applied. [MEDICATION NAME] was administered twice for pain and the [MEDICATION NAME] was continued. * On 6/11/18 at 3:09 PM, the dressing was changed to the coccyx. The wound bed was red and beefy without slough and the edge was pink. New tissue was noted throughout the wound. The current dressing order was continued. * On 6/12/18 at 2:20 PM, the dressing was changed and the wound measured 1.2 cm by 2 cm by 0.4 cm. The wound bed was red, beefy and signs of healing were present. Resident #29's (MONTH) (YEAR) TAR (Treatment Administration Record) documented a daily dressing change to the coccyx was performed each day from 5/22/18 through 5/31/18, except for 5/29/18. Resident #29's (MONTH) (YEAR) TAR documented a daily dressing change to the coccyx was performed each day from 6/1/18 through 6/5/18 and on 6/11 and 6/12/18. On 6/12/18 at 1:52 PM, RN #2 was observed changing the dressing on Resident #29's coccyx. An ulcer was present that measured 1.2 cm by 2 cm by 0.4 cm. RN #2 said the wound was healing. On 6/13/18 at 1:59 PM, CNA #3 said Resident #29 was more alert at the end of (MONTH) and would feed herself. CNA #3 said they reposition Resident #29 every two hours and it should be documented but it was not. On 6/13/18 at 2:48 PM, RN #2 said Resident #29 was doing fairly well until she got a blister on her bottom. It started as a clear blister and she did not know what caused it. The cushion was changed in her wheelchair in case it had pinched her skin, and a dressing was applied to the coccyx. RN #2 said the next time she saw the wound it was an open wound with slough. RN #2 said she applied silver alginate, and in two days the slough was gone and it was a stage 2 ulcer. The dressing was then changed to [MEDICATION NAME] and Alevyn. RN #2 said a blister could be from pressure, and when it was first brought to her attention that Resident #29 had a blister on her coccyx the staff was instructed to change the cushion in her wheelchair and keep the wrinkles out of her sheets. RN #2 said the first time she saw Resident #29's blister she thought it from being pinched, and she assumed if she put a clear dressing on it would absorb and she depended on the nurses to check on it. RN #2 said the next time she saw the blister it was an ulcer and she was not aware until sometime after the weekend that it had changed. RN #2 said she thought it was appropriate to initiate the air mattress 11 days after the blister was noticed on Resident #29's coccyx, after it became an unstageable ulcer. On 6/14/18 at 1:48 PM, RN #3 said CNAs do not document repositioning residents every two hours, and the only way to know it was done was by observation. On 6/15/18 at 9:23 AM, the DON said when Resident #29 developed a blister on her coccyx, the blanket and chair were removed. The DON said there were concerns about the incontinence briefs causing the blister, and they tried putting her in bed to keep pressure off the area. The DON said a good mattress was being used and the blister was not thought to be pressure related, and once the wound was determined to be pressure related an air mattress was implemented. The DON said an incident form was completed when the skin issue was first noticed, then another incident form was done when the wound changed. | 2020-09-01 |