| 63 |
VALLE VISTA MANOR |
275021 |
402 SUMMIT AVE |
LEWISTOWN |
MT |
59457 |
2020-01-28 |
684 |
G |
1 |
0 |
65C211 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to monitor a resident for change of condition and follow through to obtain physician consultation, which resulted in a delay in treatment and ultimately a hospitalization , for 1 (#1) of 5 sampled residents. Findings include: During an interview on 1/28/20 at 12:24 p.m., NF1 stated he had noticed a difference in resident #1's cognition and status the two days prior to the hospitalization . NF1 stated he was in to see resident #1 on Saturday, 1/4/20, around one or two in the afternoon. NF1 stated he noticed a puddle on the floor around resident #1's foot and thought it was urine. He notified the nurse, and the nurse took resident #1's sock off, and NF1 immediately noted resident #1's foot was swollen like a balloon, and the fluid matter on the floor was not urine but was coming from resident #1's foot. NF1 stated he asked the nurse if he should take resident #1 to the hospital. The nurse stated no we have a wound nurse consult scheduled for Monday (six days later). NF1 stated it should have been obvious resident #1's foot was infected. NF1 stated he had not been notified of the swelling on resident #1's foot prior to seeing it in person. NF1 stated he received a phone call around 4:30 a.m., on Sunday 1/5/20, notifying him resident #1 was being sent to the emergency room . NF1 stated resident #1 was septic (infection) by the time he was admitted to the hospital, and the resident had [MEDICAL CONDITION]. During an interview on 1/28/20 at 1:27 p.m., staff member B stated she was not present in the facility when resident #1 had been sent out to the hospital. During the weekend it was the Registered Nurse that was in charge of overseeing cares. Staff member B stated the facility had been aware of the redness and swelling of resident #1's foot on 1/3/20. On 1/4/20 it was assessed, but resident #1 did not have a temperature until 1/5/20. Staff member B stated it would be alarming if a resident presented with a swollen foot with drainage, and she would have cleaned the wound then notified the doctor and wound care nurse. During an interview on 1/28/20 at 2:25 p.m., staff member E stated resident #1 was neither resistive, nor refused cares, when provided to the resident. During an interview on 1/28/20 at 2:46 p.m., staff member A stated, during the time of resident #1's admission, since the Director of Nursing was gone, the floor nurse was in charge of overseeing and ensuring cares. Staff member A stated if there were any issues, the floor nurse could not handle the Regional Clinical Nurse would have consulted in the matter. Staff member A stated he was confused on the matter of resident #1's foot, as it was noted the resident had a fall with mention of resident #1's socks, and all extremities were checked, but there was no mention of swelling noted. It was noted on 1/3/20 and 1/4/20 the resident experienced leg pain, and the foot was swollen red and hot to the touch. Staff member A stated he did not know what happened. During an interview on 1/28/20 at 3:50 p.m., with staff member A, B, and C, staff member B stated all skin checks would be either Braden scale assessments or documented in the progress notes if they occurred. Staff member B stated there was not a physician note for 1/3/20 or 1/4/20 to show facility staff made contact with a doctor to get direction on what to do with resident #1's foot condition. Staff member B stated on 1/3/20, a wound nurse consultation had already been set up, due to the resident's avoidable pressure ulcer to his buttocks, and back. Staff member B stated there was not an official process to document the completion of a head to toe assessment after falls to ensure they were completed. Staff member B stated she did not find any other skin checks for the resident, except the skin checks completed on admission, and 1/2/20. Staff member B stated she had just implemented skin checks on bath days. Staff member C stated she was in the facility for a few hours on 1/4/20, Saturday morning. She stated she performed catheter care and wound care for the resident and did not recall if the resident had socks on or not. Staff member C stated she could not recall looking at resident #1's foot. A review of resident #1's care plan, with a last revision date of 12/31/19, showed no documentation for catheter care, wound care, or skin checks to be performed. A review of resident #1's skin and wound assessments, dated 12/12/19 and 1/2/20, showed no documentation of resident #1's foot or swelling. A review of resident #1's Nursing progress notes, showed the following: - On 1/3/20 - Residents foot is red swollen and red to the touch. Will be trying to be getting ahold of the doctor to possibly get ABX (antibiotics). - On 1/4/20 at 2:14 p.m. - Pt very lethargic and unable to perform therex to lower ext 's., R. foot is badly swollen and in need of wound care. Nurse redressing foot and calling doctor.(sic) - On 1/4/20 at 3:15 p.m. - Res (family member) in today. He is Concerned that (resident) is declining. Res has been hiccupping again this day. Upon assessing res, RLE has +3 [MEDICAL CONDITION]. R foot hs developed 4 fluid filled blisters on top of foot and one blister on sm toe that has popped. There is necrotic tissue present on toe. R foot is seeping large amounts of fluid. Tissue under blisters appears to be very dark below fluid. Foot cleansed with normal saline and super absorbent pads placed on foot, then wrapped with gauze. Foot is elevated at this time. Will send note to provider and wound care nurse. (sic) - On 1/5/20 at 4:00 a.m. - CNA reports that this resident has a temp of 101. Temporal P 110 BP 110/57 R17. Resident is very confused .MD notified, and orders received to transfer to ER for evaluation and treatment. A review of resident #1's hospitalization documentation, dated 1/5/20, showed the following: - Resident #1 was noted to have had confusion, by family, on Friday the third and Saturday the fourth, of January. - (Family Member) saw (resident #1's) right foot yesterday the surface of the little toe was blackened, swollen, and red. Family member was told by nurse they would rewrap toe and get Wound Care involved Monday (the 6th). (sic) - Resident #1 was admitted to the hospital with [REDACTED]. A request for all physician communication for resident #1's length of stay was made on 1/28/20, and no further documentation was provided by the facility. A phone call was placed to staff member F, the floor nurse during the time of resident #1's stay, on 1/28/20 at 3:17 p.m A message was left for a return call. The phone call was not returned. |
2020-09-01 |