| 50 |
BOYINGTON HEALTH AND REHABILITATION |
255092 |
1530 BROAD AVE |
GULFPORT |
MS |
39501 |
2019-03-08 |
656 |
D |
0 |
1 |
M3XR11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, facility policy review, and staff interview, the facility failed to implement the comprehensive care plans related to Residents #2, #57, and #133's wound care, and for Resident #51's catheter care. This concern was identified for four (4) of 31 care plans reviewed. Findings include: Review of the facility's policy titled, Care Plans-Comprehensive, dated 11/2017, revealed that it is the policy of this facility that a Comprehensive Care Plan that includes measurable objectives and timetables to meet medical, nursing, mental and psychological needs is developed for each resident. The facility policy stated that each resident's Comprehensive Care Plan is designed to incorporate identified problem areas, incorporate risk factors associated with identified problems, and reflect treatment goals and objectives in measurable goals. The facility policy stated that the Comprehensive Care Plan has been designed to prevent declines in the resident's functional status/ functional levels. The Comprehensive Care Plan has been designed to reflect treatment goals and objectives in measurable outcomes. The policy further stated care plans are revised as changes in the resident's condition dictate and reviews are made at least quarterly. Resident #2 A review of the Comprehensive Care Plan for Resident #2, revealed a Focus problem, initiated on 01/15/15, for Stage 4 pressure wounds to the right and left ischiums, and a Stage 4 pressure wound to the sacrum initiated on 09/10/2018. The Care Plan revealed the measurable goals stated there will have been noted improvement in size and depth of the pressure wounds to the right and left ischiums by next review with no further signs of skin integrity alterations, and no pain with wound treatment. The Target Date was 06/03/19. The Care Plan included an intervention, dated 03/05/2019, for nursing department to cleanse the wound to the left ischium, right ischium, and sacrum with Normal Saline (NS), pat dry, apply skin prep to peri-wound, Fill wound with alginate extra rope wound dressing, cover with four by four (4x4) gauze, and cover with super absorbent dry dressing daily and as needed (PRN). An observation, on 03/06/2019 at 8:46 AM, revealed Resident #2's wound care was provided by Registered Nurse (RN) #3. RN #3 performed the wound care on three (3) separate pressure wounds: A Stage 4 pressure wound to the left (L) Ischium, a Stage 4 pressure wound to the right (R) Ischium, and a Stage 4 pressure wound to the sacral area. RN #3 performed the wound care to both the Stage 4 pressure wound to the (L) Ischium and the Stage 4 pressure wound to the (R) Ischium, without incident. During the wound care on the Stage 4 pressure wound to the sacral area, RN #3 removed the soiled dressing from the wound, and then continued with the wound care by applying two (2) out of three (3) dressing ropes without washing her hands. After applying the second dressing rope, it was then that RN #3 removed her gloves, washed her hands, put on new gloves, and then continued to apply the third dressing rope into the wound. An interview with Registered Nurse (RN) #3, on 03/07/19 at 11:00 AM, revealed she did not wash her hands going from cleaning the sacral wound and discarding the soiled gauze, and applying the first two medicated rope dressings. An interview, on 03/07/2019 at 11:15 AM, with the Director of Nursing (DON), revealed Registered Nurse (RN) #3 should have washed her hands after she cleaned the sacral wound, and before she applied the medicated rope dressing. The DON also stated the staff was expected to follow the care plan. During an interview, on 03/07/2019 at 1:54 PM. with Licensed Practical Nurse (LPN) #1 / Care Plan Coordinator, it was revealed that it was the intent of developing the comprehensive care plan that the care plan was to be followed. LPN #1 stated that it was her expectation that the nurse would provide the wound care treatment, without risking the possible spread of infection. During an interview, on 03/07/2019 at 4:08 PM, with RN #1/ Care Plan Coordinator, it was revealed that it was her expectation that once the comprehensive care plan has been developed, that the care plan would be followed thereafter. RN #1 stated the discipline that the intervention task is assigned to, should perform the intervention. Review of Resident #2's Discharge Minimum Data Set (MDS), dated [DATE], revealed a Basic Interview for Mental Status (BIMS) score of 15, which indicated no cognitive impairment. Further review of the MDS revealed Resident #2 was coded for the presence of two (2) Stage 3 pressure wounds. Review of Resident #2's Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/19/18, revealed a Basic Interview for Mental Status (BIMS) score of 15, which indicated no cognitive impairment. Further review of the MDS revealed Resident #2 was coded for two (2) Stage 4 pressure wounds. Review of the Face Sheet revealed Resident #2 was admitted by the facility on 03/05/2013, and readmitted on [DATE], with [DIAGNOSES REDACTED]. Resident #51 On 3/7/19 at 2:05 PM, an observation revealed Certified Nursing Assistant (C NA) #1 performed Resident #51's catheter care. CNA #1 failed to wash her hands prior to beginning the catheter care. CNA #1 applied her gloves, pulled some clean wipes from the wipe container and began the catheter care. CNA #1 wiped around the catheter near the resident's penis three times using one wipe, and rotated the wipe as she wiped. She then used another wipe to wipe in a downward motion on the resident's groin areas, using a clean wipe for each side. CNA #1 held the catheter tubing near the meatus, and wiped away from the meatus three times. She then repositioned Resident #51 onto his left side, and cleaned his buttocks, wiping the buttock areas in a circular, and back and forth motion, using the same wipe to clean the resident's entire buttocks area. On 03/07/19 at 4:26 PM, an interview with Registered Nurse (RN) #1 revealed, she would expect the staff to implement the comprehensive care plan. Review of the Physician Orders, with a start date of 12/21/18, revealed the order to change the Foley Catheter as needed for leakage or blockage, and check the leg anchor every shift and as needed. Foley Catheter care every shift. Foley Catheter size 16 French (FR) to bedside drainage, check for patency every shift and change as needed. Review of Resident #51's most recent comprehensive MDS, with an ARD of 12/19/18, revealed Resident #51 was coded for an indwelling urinary catheter/condom catheter, and not rated for urinary continence. Further review of the MDS revealed a BIMS score of 15, which indicated Resident #51 was cognitively intact. A review of the facility's Face Sheet revealed the facility admitted Resident #51 on 03/13/18 with a [DIAGNOSES REDACTED]. Resident #57 Review of Resident #57's Comprehensive Care Plan revealed Focus for Impaired Skin Integrity, dated 12/03/18, for a Stage 2 Pressure Wound to the sacrum, and 01/23/18 for a current visual Stage 4. The Goal stated the Pressure Ulcer will show signs of healing and remain free from infection. The initial date was 01/23/19, and the Target date was 04/23/19. The Interventions included wound care as ordered dated 06/05/18. Review of Resident #57's Treatment Administration Record (TAR), for (MONTH) 2019, revealed the following: Clean Sacrum with NS (Normal Saline), Pat dry apply Santyl in a thin layer, pack with gauze and cover with silicone dressing daily and PRN (as needed). Order Date 01/08/19. An observation on, 03/07/19 at 10:15 AM, revealed Registered Nurse (RN) #3/Wound Care Nurse performed wound care to Resident #57's sacrum. RN #3 placed a red bag on Resident #57's bed to the right of the resident's right leg. RN #3 removed the old dressing, and discarded the dressing in the red bag. RN #3 washed her hands and began to clean the wound. RN #3 cleaned the wound and patted it dry. RN #3 applied the Santyl to the wound bed with a Q-tip, and covered the wound with a dressing. RN #3 used the same gloves that she had on while cleaning the wound to apply the Santyl and the clean dressing to the wound. RN #3 failed to remove her gloves, wash her hands and re-glove after cleaning the wound, and before applying the Santyl and the clean dressing to the wound. An interview, on 03/07/19 at 10:48 AM, revealed RN #3 confirmed, she knew what she did when she did it. RN #3 stated she didn't change gloves and wash her hands after cleaning the wound, and before she applied the Santyl and the clean dressing. An Interview, on 03/08/19 at 8:37 AM, revealed Licensed Practical Nurse (LPN) #1/Care Plan Nurse stated, If Resident #57 had a care plan created for wound care then she would expect the care plan to be followed. Review of Resident #57's Significant Change MDS, with an ARD of 01/11/19, revealed a BIMS score of 10, which indicated moderate cognitive impairment. Further review of the MDS revealed Resident #57 was coded for an unstageable wound. Resident #133 Review of Resident #133's Care Plan revealed a Focus, dated 03/04/19, for impaired skin integrity due to a wound to the right foot related to amputation of the right great toe. The Goal stated the wound to the right great toe would show signs of healing by/through the review date. The Goal was initiated on 03/04/19, and the Target Date was 06/02/19. The Interventions included the physician's orders [REDACTED]. 1/2 strength wet to dry packing. Cover with 4x4s and wrap with Kerlix PRN (as needed) when wound vac is reapplied. Start Date 03/04/19. (2) Wound vac (negative pressure wound therapy) in place to wound to right great toe amputation site. Apply wound vac at amputation site at 125 mmHg (millimeters of Mercury) Change Q (every) Tuesday and Friday. Start Date 03/04/19. An observation, on 03/05/19, 4:40 PM, revealed Registered Nurse (RN) #3/Wound Care Nurse provided Resident #133's wound care to the right foot/great toe. RN #3 was assisted by Certified Nursing Assistant (CNA) #3. RN #3 set up the wound care supplies on the over bed table, and then she placed the red biohazard bag on Resident #3, which positioned the right toe wound between RN #3 and the red biohazard bag. After looking over the supplies RN #3 identified she forgot to get scissors from the wound care cart. RN #3 left the room, and returned with the scissors in her bare hands. RN #3 laid the scissors on the tray containing her clean dressings without cleaning the scissors. RN #3 removed the dirty dressing, and discarded it into the red biohazard bag. RN #3 washed her hands and gloved to begin cleaning the wound. RN #3 wiped the wound with normal saline soaked gauze, and discarded the gauze into the red bag. RN #3 got another piece of normal saline gauze, wiped the other side of the wound, and discarded the gauze into the red bag. RN #3 took another piece of the normal saline gauze, wiped the wound, and the normal saline dripped down the side of the foot. RN #3 took the same piece of gauze and reached down to catch the dripping saline and wiped back towards the cleaned wound going from an uncleaned area to a cleaned area, thus wiping dirty to clean. RN #3 did not reclean the wound before attempting to apply the wound vac to the wound. RN #3 washed her hands and gloved, and then picked up the foam that was to be packed into the wound and crossed the cleaned wound over to the red bag and held the foam above the red bag, with the dirty dressing and gauze in it, and began trimming the foam with the uncleaned scissors. RN #3 brought the foam from over the red bag back to the wound, and placed it on the wound. She then reached back over and got the second piece of foam and crossed the clean wound again going to the red bag. RN #3 began trimming the foam over the red bag, and then brought the foam back and placed it on wound. She picked up the end of the wound vac that was to be placed over the foam on the wound. RN #3 placed the wound vac tubing on Resident #133's gown. The end to the tubing was uncapped. RN #3 sealed the part of the wound vac with the dressings cut earlier. She then picked up the tubing from the gown and hooked it to the wound vac itself without cleaning the uncapped tube. Suction was obtained. RN #3 cleaned up her trash, washed her hands, and exited the room. An interview, on 03/05/19 at 5:10 PM, with RN #3/Wound Care Nurse revealed, I did wipe the wound from dirty to clean and I knew it when I did it. RN #3 stated, I didn't think about crossing over the wound to the red bag with the foam then bringing it back over and putting it in the wound. I can see where that would be a contamination issue. I cleaned the scissors before bringing them in the room, but I didn't reclean them after bringing them into the room in my hand. I didn't think about that being an issue but I can see where they could be considered dirty being toted in my bare hand. I held the foam above the red bag to trim it, and I wasn't thinking about it being a contamination issue since I didn't touch it. But with the dirty dressing being in the red bag I can see it being a issue. Record review of Resident #133's Physician order [REDACTED]. 1/2 strength wet to dry packing. Cover with 4x4s and wrap with Kerlix PRN (as needed) when wound vac is reapplied. Start Date 02/27/19. (2) Wound vac (negative pressure wound therapy) in place to wound to right great toe amputation site. Apply wound vac at amputation site at 125 mmHg (millimeters of Mercury) Change Q (every) Tuesday and Friday. Start Date 02/26/19. During an interview, on 03/08/19 at 8:37 AM, Licensed Practical Nurse (LPN) #1/Care Plan Nurse revealed she would expect a resident's care plan for wound care would be followed. Review of the Face Sheet revealed Resident #133 was admitted by the facility, on 02/12/19, with the included [DIAGNOSES REDACTED]. Review of Resident #133's Admission MDS, with an ARD of 02/19/19, revealed a BIMS score of 11, which indicated moderate cognitive impairment. Further review of the MDS revealed Resident #133 was coded for a Stage 2 wound. |
2020-09-01 |