| 31 |
BELLA TERRA OF BILLINGS |
275020 |
1807 24TH ST W |
BILLINGS |
MT |
59102 |
2018-03-21 |
686 |
G |
1 |
0 |
U1E811 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, interview, and observation, the facility failed to prevent the development of one unstageable pressure ulcer on the spine; and failed to have the supplies necessary for the physician-prescribed treatment order for a Stage IV pressure ulcer on the coccyx, for 1 (#2) of 11 sampled residents. Findings include: 1. Review of resident #2's At Risk report, dated 2/20/18, showed During rounds licensed nurse called writer to room of resident. Resident was lying on left lateral side. There were two red and blanchable skin spots on her posterior spine. There was one 1 X 1 unstageable on mid- [MEDICATION NAME]. The root cause was resident is very kyphotic and tends to lean against the back of the wheelchair, creating pressure points on back. Referral to therapy. Review of resident #2's physician order, dated 2/21/18, showed Skin prep wipes every morning and at bedtime for skin breakdown. And Resident to return to bed after each meal due to skin breakdown along spine, limited to one hour up maximum. Review of resident #2's Progress Note, dated 2/22/18, showed apply [MEDICATION NAME] dressings to spinal area and change every two days. During an observation on 3/20/18 at 1:20 p.m., resident #2 was up in her chair, after the 12 o'clock meal. There was no cushion to the back of her chair. At 2:30 p.m., resident #1 was still up in her chair. During an interview on 3/20/18, staff member [NAME] stated resident #2 did not like to return to her bed. Review of resident #2's Physician order, dated 3/9/18, showed PT to evaluate for back cushion in wheelchair 17 days after the pressure area and root cause were discovered. Review of resident #2's therapy evaluation for a back cushion for pressure relief, showed it did not occur until 3/20/18, during the survey investigation, and one month after the pressure ulcer was identified. Review of resident #2' Care Plan, dated 11/15/17, showed no identification of the spine pressure ulcer, or evidence of pressure relief for the spine. During an interview on 3/21/18 at 8:10 a.m., staff member D stated the facility had been watching the pressure area very closely, and she believed the resident had, at one point, a cushion for the back of the wheelchair. Weekly skin documentation for resident #2 was requested on 3/20/18. No skin checks were provided for the unstageable pressure area on the spine. 2. Review of resident #2's Progress Note, dated 3/9/18, showed the [DEVICE] was discontinued, for the Stage IV coccyx pressure ulcer. The treatment was changed to cleanse wound with normal saline, apply Iodosorb to alginate and pack in wound, cover with foam dressing. During an interview on 3/20/18 at 1:20 p.m., staff member C stated the facility was out of Iodosorb, and could not complete resident #2's dressing change. She stated staff member G was out of the facility looking for the treatment. During an interview on 3/20/18 at 1:30 p.m., staff member G stated the facility did not carry the Iodosorb, and the Hospice nurse would bring the supplies to the facility, and do the dressing change. Review of resident #2's Physician order [REDACTED]. During an interview on 3/21/18 at 8:40 a.m., staff member C stated Hospice did not have the Iodosorb dressing, so the order was changed. The facility was unable to determine if the prescribed Iodosorb treatment was provided from 3/9/18 to 3/20/18. During an interview on 3/20/18 at 10:40 a.m., staff member [NAME] stated the nursing department had difficulties getting the medications and supplies they needed from central supply. It does not flow well and it is not safe for the residents. During an observation on 3/21/18 at 9:10 a.m., of a dressing change to resident #2's pressure ulcer, the dressing from the day before was not dated, and there was no packing removed during the dressing change, as ordered by the physician. |
2020-09-01 |