| 59 |
BOYINGTON HEALTH AND REHABILITATION |
255092 |
1530 BROAD AVE |
GULFPORT |
MS |
39501 |
2017-05-18 |
514 |
E |
1 |
0 |
UDH111 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview and record review the facility failed to ensure accurate and completely documented medical records as evidenced by conflicting information about wounds and whether they were acquired or admitted , where they were located and types of wounds for five (5) of seven (7) residents reviewed with pressure sores; Residents #7, #10, #11, #12, and #13. Findings include: Resident #7: Review of the Weekly Wound Information Sheet, for Resident #7, revealed the following wound assessments: 1. Right Ankle: weekly documentation present with conflicting information: 03/7/17- Right Ankle Pressure Ulcer, acquired 11/2/16, originally unstageable with current stage III. 03/28/17-Documentation changed to Right lateral ankle pressure ulcer, originally unstageable with current stage II. 05/10/17-Documentation goes back to Right Ankle pressure ulcer, admitted on [DATE] as a current stage II with no original staging. 2. Left Ankle: weekly documentation present with conflicting information: 3/7/17-Left ankle Pressure Ulcer, acquired 11/14/16, originally unstageable with current stage III. 3/28/17-Changed to Left lateral ankle pressure ulcer, originally unstageable with current stage III. 5/10/17-Goes back to Left ankle pressure ulcer, now as admitted with on 5/4/17, no original stage recorded, current stage II. 3. Sacrum: weekly documentation present with conflicting information: 3/7/17-Sacrum, Pressure Ulcer, admitted as stage IV on 10/14/16, with current stage IV and original Stage IV. 5/10/17-Sacrum, Pressure Ulcer, changed to admitted with on 5/4/17 with current stage of III and original stage was not documented. Review of Resident #7's current care plan did not reveal the type of wounds or stages of the ankle wounds. Interview, on 05/16/17 at 12:30 PM, with the MDS/CP LPN (Minimum Data Set/Care Plan Licensed Practical Nurse) confirmed neither pressure ulcers for the ankles on Resident #7 included the stage of the pressure ulcers. Review of the Admission Record revealed the facility readmitted Resident #7 on 12/22/16, with [DIAGNOSES REDACTED]. Review of the quarterly MDS, with an Assessment Reference Date (ARD) of 03/18/17, revealed he scored 9 of 15 on the Brief Interview for Mental Status (BIMS), which indicated he had moderate cognitive impairment. Resident #10: Review of the Weekly Wound Information Sheet, for Resident #10, revealed the following wound assessments: weekly documentation with conflicting information: 3/2/17-sacrum pressure ulcer, admitted [DATE] originally a stage III and currently a stage III. 5/2/17-sacrum pressure ulcer, acquired 6/6/14, originally a stage III with current stage III. 5/9/17-sacrum pressure ulcer, switched back to admitted on [DATE], originally and currently a stage III. 5/16/17-sacrum pressure ulcers switched to acquired on 3/18/17, original and current stage III. Review of the Admission Record revealed the facility admitted Resident #10 on 6/6/14, and readmitted Resident #10 on 03/18/17, with [DIAGNOSES REDACTED]. Review of the quarterly MDS, with an ARD of 04/30/17, revealed the Resident scored 15 of 15 on the BIMS, which indicated he was cognitively intact. Resident #11: Review of the Weekly Wound Information Sheet, for Resident #11, revealed the following wound assessments: 1. Left Ischium: weekly documentation present with conflicting information: 3/3/17-Left Ischium pressure ulcer, admitted with on 2/6/17, originally and currently a stage II. 3/17/17-Changed to Left Buttock pressure ulcer, still admitted with on 2/6/17, originally and currently a stage II. 3/31/17-Changed back to Left Ischium pressure ulcer, still admitted on [DATE], originally and currently a stage II. 5/10/17-Left Ischium pressure ulcer, with an acquired date of 5/8/17, originally and currently a stage II. 2. Right Ischium: weekly documentation present with conflicting information: 3/3/17-Right Ischium pressure ulcer, admitted [DATE], originally and currently a stage II. 3/17/17-Right Ischium pressure ulcer changes to acquired on 2/6/17, originally and currently a stage II. 4/7/17-Right Ischium pressure ulcer changes back to admitted with on 2/6/17, original and current stage II. 5/17/17-Right Ischium pressure ulcer changes back to acquired on 5/8/17, stage II original and current. Review of the Admission Record revealed the facility admitted Resident #11 on 08/22/16, with [DIAGNOSES REDACTED]. Review of the quarterly MDS, with an ARD of 02/23/17, revealed he scored 3 of 15 on the BIMS, which indicated he had severely impaired decision making abilities. Resident #12: Review of the Weekly Wound Information Sheet, for Resident #12, revealed the following wound assessments: 1. Right Heel: weekly documentation present with conflicting information: 4/14/17-Right Heel pressure ulcer, acquired 4/13/17, originally and currently stage II. 5/11/17-Right Heel pressure ulcer has an acquired date of 2/2/17, original and current stage II. 5/17/17 Right heel pressure ulcer also had the acquired date of 2/2/17. 2. Right Buttock: weekly documentation present with conflicting information: 3/3/17-Right buttock pressure ulcer, admitted [DATE], original and current stage IV. 4/28/17-Right buttock pressure ulcer changed to admitted with on 3/5/17 with original and current stage IV. 5/5/17-changes to Right Ischium pressure ulcer, present on admission on 3/5/13 with original and current stage IV. 5/11/17-Right Ischium (Buttock) pressure ulcer, present on admission on 3/5/13, original and current stage IV. 5/17/17-Right Ischium, present on admission 3/5/13 with original stage IV and current stage III. 3. Left Buttock-weekly documentation present with conflicting information: 3/3/17-Left Buttock pressure ulcer on admit 3/5/13, original and current Stage IV. On 4/21/17 the measurements were 8.0 centimeters (cm) long by (x) 6.2 cm wide by 1.0 depth, then on 4/28/17 the measurements were 3.8 cm x 2.0 cm x 1.0 cm. On 5/5/17 the measurements went back to 8.2 cm x 6.3 cm x 1.0. 5/5/17-changes to Left Ischium pressure ulcer, present on admit 3/5/13 with original stage IV and current stage III. 5/11/17-Left Ischium (Left Buttock) pressure ulcer, admitted [DATE] with original stage IV and current stage III. 5/17/17-Left Ischium pressure ulcer only, admitted [DATE] with original stage IV and current stage III. There was no documentation on the care plan to indicate type and stage of wounds. Interview, on 05/17/17 at 10:40 AM, with the MDS/CP Licensed Practical Nurse (LPN) stated she did review the weekly wound report, but had not been instructed to include the stage and cause of the wound in the Care Plan. Review of the Admission Record revealed the facility admitted Resident #12 on 3/5/13, and readmitted Resident #12 on 01/21/15, with [DIAGNOSES REDACTED]. Review of the quarterly MDS, with an ARD of 03/14/17, for Resident #12 revealed he scored 15 of 15 on the Brief Interview for Mental Status BIMS, which indicated he was cognitively intact. Resident #13: Observation of Resident #13's wounds/dressings on 5/17/17 at 9:20 AM, revealed a wound on the right shin, the left lateral leg at the ankle, left ishium and coccyx. Review of the Weekly Wound Information Sheet, for Resident #13, revealed the following wound assessments: 1. Sacrum-Weekly documentation present with conflicting information: 5/5/17-Sacrum pressure ulcer, acquired 4/30/17, original and current stage III. 5/11/17-changed to Coccyx pressure ulcer with the same information. 2. Left Lateral Leg #1: Weekly documentation present with conflicting information: 5/5/17-Left Lateral Leg #1, acquired 4/30/17, pressure ulcer, original and current unstageable. 5/18/17-changed to Left lower leg #1 pressure ulcer with the same information. 3. Left Lateral Leg #2: Weekly documentation present with conflicting information: 5/5/17-Left Lateral Leg #2 pressure ulcer, acquired 4/30/17, unstageable originally and currently. 5/18/17-changed to Left lower leg #2 pressure ulcer, acquired on 5/11/17, original and currently unstageable. 4. Right Shin: Weekly documentation present with conflicting information: 5/11/17-Right shin pressure ulcer, acquired 5/6/17, original and currently unstageble 5/18/17-Right shin pressure ulcer, acquired 4/30/17 with the same information. 5. Right upper Leg: Weekly documentation present with conflicting information: 3/10/17-Right upper leg pressure ulcer, acquired 1/25/17, original and current stage II. 5/5/17-Right upper leg pressure ulcer changed to acquired on 5/5/17, original and current stage III. 6. Right Posterior Thigh: Weekly documentation present with conflicting information: 5/11/17-Right Posterior Thigh pressure ulcer, admitted with on 1/25/17, original stage not documented, current stage III. 5/18/17-Right Posterior Thigh pressure ulcer, changed to acquired on 2/20/17, original stage II and current stage II. Review of Resident #13's current care plan revealed the wounds were not identified as to the stage and type of the wounds present on Resident #13. Interview, on 05/17/17 at 10:25 AM, with the MDS/CP LPN, confirmed the wounds for Resident #13 were not identified on the Care Plan with the stage or type of ulcers (pressure). Review of the Admission Record revealed the facility admitted Resident #13 on 2/27/14 and readmitted Resident #13 on 03/07/17, with [DIAGNOSES REDACTED]. Review of the admission MDS revealed the Resident scored 15 of 15 on the BIMS, which indicated he was cognitively intact. |
2020-09-01 |