| 94 |
THE PILLARS OF BILOXI |
255093 |
2279 ATKINSON ROAD |
BILOXI |
MS |
39531 |
2019-05-15 |
686 |
D |
0 |
1 |
0E0S11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, facility policy review, record reviews, and interviews the facility failed to provide the treatments as ordered for a pressure ulcer for one (1) of five (5) residents, Resident #104, reviewed for pressure ulcers, in a sample of 24 residents. Not providing treatment as ordered, had the potential for the pressure ulcer to deteriorate. Findings include: Review of a facility's policy titled Skin Care Process, dated 1/17/18, revealed, It is the policy of this facility to provide care and services with the goal of maintaining the resident's skin integrity and to provide care and services that meet professional standards to treat the loss of skin integrity should it occur .1. Provides treatment according to physician's orders [REDACTED]. Review of Resident #104's undated Face Sheet found in the electronic record, revealed the resident was admitted to the facility on [DATE], with the [DIAGNOSES REDACTED]. Review of a quarterly Minimum Data Set (MDS) with the assessment reference date of 4/30/19, revealed Resident #104 had a BIMS (Brief Interview for Mental Status) of 15, which indicated the resident was alert and oriented. The MDS indicated Resident #104 required extensive assist of two (2) staff for bed mobility, transfer, dressing toilet use and personal hygiene. The MDS documented Resident #104 did not have any pressure ulcers at the time of the assessment. Review of an undated care plan for pressure ulcers, revealed Resident #104 had a Stage 2 pressure ulcer to the left medial thigh. The interventions for the Stage 2 pressure ulcer were: Administer medications as ordered; Monitor/document for side effects and effectiveness; Administer treatments as ordered and monitor for effectiveness; Assess/record/observe wound healing; Measure length, width, and depth where possible; Assess and document status perimeter, wound bed and healing progress; Report improvements and declines to the MD (Medical Doctor). Observe nutritional status; Serve diet as ordered, monitor intake and record; Observe/document/report PRN (as necessary) any changes in skin status: appearance, color, wound healing, s/s (signs and symptoms) of infection, wound size (length x(times) width x depth), stage comfort; Treat pain as per orders prior to treatment/turning to ensure the resident's comfort; Weekly treatment documentation to include measurements of each area of skin breakdown's width, length, depth, type of tissue and exudate. Review of the facility's Pressure Injury Log, dated 5/10/19, revealed Resident #104 had a facility acquired pressure ulcer measuring 1.7 by .06 centimeters (cm) which was fluid filled. The treatment order was [MEDICATION NAME] twice a day. Review of the 05/2019 Treatment Administration Record, specified wound care apply [MEDICATION NAME] and tented border gauze to Stage 2 pressure ulcer of L (left) medial thigh, 7-10 AM and 7-10 PM. Start date 5/03/19. Further review of the treatment record indicated the dressing was not completed at all on 5/04/19, the morning of 5/06/19, the afternoon of 5/08/19, and the morning 5/12/19. On 5/12/19 at 1:04 PM, the dressing to Resident #104's left thigh was observed with a date of 5/10/19, the initials on the dressing were smeared and unreadable. The resident stated she had gotten a blister from her compression stocking. Resident #104 stated the dressing had not been changed twice a day as ordered on [DATE] and 5/12/19. During an interview on 5/14/19 at 8:50 AM, Resident #104 stated the midnight nurse had changed the dressing. The resident said the dressing to her left thigh was to be changed twice a day, and that was not done on 5/13/19 as ordered. The date on the dressing was observed as 5/14/19. During a telephone interview on 5/15/19 at 11:AM, the RN Wound Nurse indicated she had changed the dressing on 5/14/19, and the daily dressing changes had not been getting done. The Wound Nurse said she changed the dressings weekly when she did wound measurements, and the floor nurses did the daily treatments. During an interview on 5/15/19 at 1:00 PM, the RN TCU (Transitional Care Unit) Unit Manager (UM) confirmed the dressings should have been done, and she would look into the matter. The TCU UM did not provide any additional information regarding why the dressing changes had not been done. At 1:22 PM, the TCU UM stated she had not been aware the dressings had not been done as ordered for Resident #104. The RN Wound Nurse completed a dressing change on 5/16/19 at 8:10 AM. The Resident #104 agreed to an observation of the dressing change. Appearance of the pressure ulcer revealed the fluid in the blister had been absorbed and the wound bed was dry. The RN Wound Nurse stated she was going to call the Nurse Practitioner because the wound had improved, and she now needed the dressing order discontinued to leave the wound open to air to heal. |
2020-09-01 |