| 60 |
BOYINGTON HEALTH AND REHABILITATION |
255092 |
1530 BROAD AVE |
GULFPORT |
MS |
39501 |
2019-08-29 |
656 |
G |
1 |
0 |
QXL511 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, staff interview and facility policy review, the facility failed to implement Resident #3's Care Plan for high risk for skin impairment. The facility failed to perform weekly body audits to monitor, assess and prevent the reoccurrence of a pressure ulcer. The facility identified Resident #3 at high risk for pressure ulcers on admission, 02/06/19, due the presence of a Stage 3 sacral pressure ulcer. As a result, Resident #3 suffered harm due to the development of a Stage 3 sacral pressure ulcer identified, on 05/09/19, which required hospitalization for wound infection and debridement of the wound. This concern was identified for one (1) of six (6) wound care plans reviewed. Findings Include: Record review of the facility's policy titled, Comprehensive Care Plan Policy, dated (MONTH) (YEAR), revealed a Comprehensive Care Plan that includes measurable objectives and timetables to meet resident's medical, nursing, mental and psychological needs shall be developed for each resident. An interdisciplinary team, in coordination with the resident, his/her family or representative, develops and maintains a Comprehensive Care Plan for each resident. The Comprehensive Care Plan has been designed to incorporate identified problem areas, incorporate risk factors associated with identified problems, build on residents strength, reflect treatment goals and objectives in measurable outcomes, Identify the professional services that are responsible for each element of care, prevent declines in the resident 's functional status/functional levels, enhance the optimal functioning of the resident by focusing on a rehabilitative program, ensure care plan is individualized and person-centered and reflects the resident's goal for admission and desired outcomes, and discharge plans. Review of the facility's policy titled, Prevention of Pressure Ulcers, dated (MONTH) 2019, revealed the skin observation schedule would be completed as follows: C.N.[NAME] (Certified Nursing Assistants) will complete total body observations at minimum on bath days. Charge Nurse will complete weekly skin observations on each resident, Licensed Nurse Weekly Skin Observation Form. Any residents with wounds will be documented on the Weekly Wound Information Sheet. The Care Plan will be revised/updated. Record review of Resident #3's Comprehensive Care Plan revealed the Focus, no date, for high risk for impaired skin integrity related to (r/t) occasional Bowel Incontinence, Diabetes, [MEDICAL CONDITION] and Actual Sacral Wound acquired on 05/09/2019. Interventions included Skin Observations weekly, and the staff assigned was the nurse. Further review of the Care Plan revealed a Focus for high risk for altered behavioral patterns as evidenced by the resident was short tempered with staff, and had episodes of cursing, attempting to hit staff, hitting and pinching staff when she does not want them to provide care. Resident also declines weights and medications at times. During an interview, on 08/29/19 at 10:00 AM, Registered Nurse (RN) #1/Treatment Nurse revealed Resident #3 was admitted with a healing Stage 3 sacral pressure ulcer on 02/06/2019. RN #1 stated the wound was healed on 02/21/2019. RN #1 said a Certified Nursing Assistant told her to check Resident #3's buttocks on 05/09/2019. RN #1 said Resident #3 was noted with a 10 centimeter (cm) x 5 cm unstageable sacral wound with a small amount of serosanguineous drainage. RN #1 reported the wound bed was covered with slough, and progressively worsened. RN #1 said she had not seen Resident #3's buttocks since 02/22/2019 (the date the sacral pressure ulcer had healed at the time of admission). RN #1 said the nurses on the floor are responsible for doing the body audits every week. RN #1 confirmed Resident #3 was considered high risk for the wound to reopen on her sacrum because she was obese, Diabetic, Chronic Urinary Tract Infections (UTIs), and a History of Pressure Ulcers. Review of Resident #3's medical record revealed no Weekly Skin Observations Forms were located from 02/21/19 until 05/09/19. Review of Resident #3's (MONTH) 2019 Treatment Administration Record (TAR), revealed an order dated 05/09/19 to cleanse the wound to the sacrum with Normal Saline (N/S). Pat dry. Apply Santyl to wound. Apply [MEDICATION NAME] to periwound. Cover with dry dressing daily and as needed (PRN) for soiled/dislodged dressing every day shift. Review of the hospital Emergency Department (ED) notes revealed Resident #3's service time and date was 05/22/19 at 12:59 PM. History of Present Illness: She was sent in because of change in hydration and alertness. Decreased diet and is refusing to take medications, meals, and fluids. Level of consciousness was alert, awake, and aware. Calm and cooperative. [DIAGNOSES REDACTED]. Review of the hospital Discharge Summary revealed Resident #3 was admitted to the hospital, on 05/22/19, and discharged on [DATE]. Resident #3 underwent an Excisional Debridement of a 15 cm X 15 cm sacral and bilateral gluteal stage IV (4) decubitus ulcer. Incision and drainage of a left medial abcess. The discharge [DIAGNOSES REDACTED].[MEDICAL CONDITION], unspecified organism. Initial blood culture was positive for Staphylococcus lugdunensis. Repeat blood cultures were negative. Acute Urinary Tract Infection: Urine cultures were positive for Kliebsiella pneumonia and [MEDICATION NAME] faecalis. Sacral Decubitus Ulcer. Acute [MEDICAL CONDITION]. An interview with the Director of Nursing (DON), on 08/09/2019 at 2:00 PM, revealed the facility failed to follow Resident #3's Care Plan for high risk for skin alterations. The DON revealed she was not the DON at that time, however she was able to confirm the facility had not done weekly body audits for Resident #3 since the sacral pressure ulcer healed on 02/21/19. The DON revealed, as the DON she was responsible to ensure the Care Plans were accurate and implemented, but due to her new position as DON, she had not accomplished reviewing the care plans for accuracy and implementation at this time. The DON said the floor nurses were scheduled to do body audits on different residents every shift. The DON also said Resident #3 was a high risk for pressure ulcers because she had just healed from a wound, was unable to turn herself and was incontinent. The Certified Nursing Assistants (CNAs) who were assigned to provide Resident #3's care and the Licensed Practical Nurse (LPN) who was responsible to perform Resident #3's weekly body audits from 02/21/19 to 05/09/19 were no longer employed at the facility. The SA made phone call attempts to interview these employees, but either the phone was no longer in use, or no answer, and/or no return calls. Review of Resident #3's Admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/12/19, revealed the resident was admitted with the presence of one (1) Stage 3 pressure ulcer, and was identified as high risk for pressure ulcers. Resident #3's Basic Interview for Mental Status (BIMS) score was 14, which indicated no cognitive impairment. Review of Resident #3's Functional Status revealed she required: Extensive assistance with two persons physical assist with bed mobility, transfers, and toilet use. Total dependence with one person's physical assist with locomotion on and off the unit. Supervision with set up help with eating. Extensive assistance with one person's physical assist with personal hygiene and bathing. Resident #3 was always incontinent of bowel and bladder. Resident #3 had Range of Motion (ROM) impairment to her upper and lower extremities on one side. An interview with Licensed Practical Nurse (LPN) #1/Care Plan Nurse, on 08/29/2019 at 1:00 PM, revealed the facility failed to implement Resident #3's Care Plan regarding the high risk for skin alterations due to the nurses failed to perform the weekly body audits to assess the resident for pressure ulcers. LPN #1 confirmed the weekly body audits were performed to assess for and prevent new pressure ulcers, and she would expect the nurses to follow the Care Plan. A review of the facility's Face Sheet revealed Resident #3 was admitted by the facility, on 02/06/19, with the included [DIAGNOSES REDACTED]. A review of Resident #3's Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 5/15/2019, revealed Resident #3 had a Brief Interview for Mental Status (BIMS) score of 5 which indicated the resident was cognitively impaired. Resident #3's Skin Condition revealed the presence of an unstageable pressure ulcer. Further review of the MDS revealed Resident #3's Functional Status: Transfers and locomotion on and off the unit was coded an eight (8), which indicated the activity did not take place. Dressing, bathing and toilet use, Resident #3 was totally dependent, and required one person's physical assist. Eating required supervision and set up help. Personal hygiene required extensive assistance with one person's physical assist. Resident #3 was always incontinent of bowel and bladder. Resident #3. Resident #3 had Range of Motion (ROM) impairment to her upper and lower extremities on one side. |
2020-09-01 |