| 64 |
VALLE VISTA MANOR |
275021 |
402 SUMMIT AVE |
LEWISTOWN |
MT |
59457 |
2020-01-28 |
686 |
D |
1 |
0 |
65C211 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to monitor an identified reddened skin area, and implement interventions for prevention of further deterioration, for the skin area, and the area worsened to an avoidable Stage II Pressure Ulcer; and the facility failed to identify the risk of the pressure ulcer development and revise interventions for a resident with a reoccurring pressure ulcer, for 2 (#s 1 and 2) of 5 sampled residents. Findings include: 1. During an interview on 1/28/20 at 12:24 p.m., NFI stated resident #1 had a red spot on admission that was not open. NF1 stated resident #1 was not repositioned, and the pressure ulcer worsened at the facility to the point resident #1 was uncomfortable when sitting. NF1 stated he was not sure if resident #1 moved nearly enough. NF1 stated he was aware of an order from the doctor for the pressure ulcer but was not sure if it had been adhered to. During an interview on 1/28/20 at 1:27 p.m., staff member B stated she was not in the facility for resident #1's admission, and she was not sure how resident #1 acquired the avoidable Stage II pressure ulcer. Staff member B stated the facility has not had many pressure ulcers and had recently implemented a system of caring for pressure ulcers. Staff member B stated the system included that a nurse would complete a skin assessment weekly, on a bath day, for a resident. Staff member B stated the implementation of the system was evaluated and is an ongoing process. Staff member B stated the resident had a head to toe evaluation in his progress note, after the abundant number of falls the resident had, during his stay at the facility. Staff member B stated resident #1 had Braden Scale skin assessments completed on the 19th, and the 26th of December, 2019, as well as on January 2nd, of 2020. During an interview on 1/28/20 at 2:46 p.m., staff member A stated resident #1 had a pressure skin injury he acquired during his stay at the facility. A review of resident #1's Comprehensive Skin Assessment, dated 12/12/19, showed redness to resident #1's coccyx. No other comprehensive skin assessments were provided by the facility for resident #1. A review of resident #1's Progress notes, showed the following: - On 12/12/19, resident #1 had a reddened area on his coccyx. -On 1/2/20, resident #1's, Skin check performed today, and mid coccyx area has a 0.5 cm X 0.5 cm X 0.1 stage 2 pressure sore noted. Area around is sore on bilateral coccyx is slightly macerated, red, scabby and fragile. This area cleansed with NS, patted dry with gauze, Opti foam adhesive placed with [MEDICATION NAME] around other closed areas of skin. Resident reported that it was sore and tolerated the procedure well. Resident then placed in his bed to help alleviate pressure and will plan to help turn and reposition often to relieve pressure and to continue with dressing changes. (Physician) will be notified via fax with this nurse note and TAR updated. (sic) -No monitored skin checks were noted in the medical record from 12/13/19 to 1/1/20 for resident #1. A review of resident #1's Care plan, last revision date of 12/31/19, showed no documentation of resident #1 being at risk for developing pressure sores, and no preventative interventions were noted for the prevention of pressure sores. A review of resident #1's Braden Scale Assessments, showed the following: - On 12/12/19, upon admission resident #1 scored a 16 on the assessment, and the score showed he was at risk for developing pressure sores. -On 12/19/19, 12/26/19, and 1/2/20, resident #1's assessment showed the resident scored a 17, and the score showed he was at risk for developing pressure sores. A review of resident #1's Initial Weekly Wound Documentation Form, dated 1/2/20, showed a Stage II Pressure Ulcer to the middle coccyx, measuring .5 cm x .5 cm x .1 cm, which was intact, macerated, [DIAGNOSES REDACTED], calloused edges, and no drainage. A box for pain associated with the wound was checked on the form. Under wound treatment and pain it showed, Change dressing daily with NS, gauze, [MEDICATION NAME] and [MEDICATION NAME] to bordered areas as needed. A review of resident #1's Physician Order, dated 1/2/20, showed Pressure ulcer of unspecified site, stage 2. Instruction to nursing home. Note to provider: 1) Start burst of [MEDICATION NAME] for back; 2) [MEDICATION NAME] to pressure ulcer in coccyx; 3) Frequent repositioning to off load; 4) Gel cushion (if available); 5) Wound nurse consulted. A review of resident #1's Verbal Physician Order, dated 1/2/20, showed, Assess bilateral coccyx daily and provide wound care: Cleanse with NS, pat dry with gauze to secure. Apply [MEDICATION NAME] to surrounding areas as needed. Discontinued when healed. every shift for Skin Care. A review of resident #1's Treatment Administration Record, showed the following: - In December 2019, resident #1 was to have weekly skin checks. No documentation of skin checks was provided by the facility, but they were initialed as completed on 12/19/19 and 12/26/19. Also, noted with a start date of 12/12/19, and an end date of 12/22/19, was, Please complete assessments. Do not sign off if not finished scheduled for two times a day. Resident #1 was monitored for pain for the month of December 2019 and January 2020. Resident #1 rarely had pain in the month of December 2020 and no pain was indicated on his pain assessments during the month of January 2020. Resident #1 had an as needed order for Tylenol for pain. - In January 2020, resident #1's wound care treatments were documented on 1/2/20 with a skin assessment, however the resident had no documented treatments on 1/4/20 to apply [MEDICATION NAME] to pressure ulcer on coccyx; reapply as needed. Frequent repositioning. A review of resident #1's emergency room Report, dated 1/5/20 showed the following: - (Resident #1) was then seen in the clinic on January 2nd by (Physician). At that time, he was noted to have pressure ulcers starting on his coccyx and buttock with a small, open wound. - Exam of his coccyx, shows an approximately 10 x 12 cm area of [DIAGNOSES REDACTED] consistent with an early pressure ulcer. On the superior aspect there is an area of about 1 to 1.5 cm that is an open wound. A review of resident #1's bathing record tasks for December 2019 and January 2020, showed no task for a bath skin check. 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. 2. During an interview on 1/28/20 at 1:27 p.m., staff member B stated resident #2's pressure ulcer had been going on before her time at the facility. Staff member B stated resident #2's pressure ulcer would heal and then reopen. Staff member B stated resident #2 had recently had a wound nurse consult for the pressure ulcer. Staff member B stated the interventions utilized for prevention of pressure ulcers included an air pressure relieving mattress, and a pressure relieving cushion, for resident #2's wheelchair. Staff member B stated resident #2's wound care order was to cleanse and apply collagen to the pressure ulcer. Staff member B stated the wound is monitored through weekly wound assessments. Staff member B stated resident #2 had an increase in her [MEDICATION NAME] for pain management and receives health shakes for nutritional intervention. Staff member B stated due to resident #2's dementia, staff remind her to reposition herself in her chair. During an interview on 1/28/20 at 2:28 p.m., staff member D stated resident #2 received skin checks every week. Staff member D stated resident #2's treatment was collagen with collagen powder, hoping to thicken the skin that keeps opening. Staff member D stated resident #2 tends to slide on surfaces that cause the wound to reopen. Staff member D stated resident #2 had a pressure relieving mattress and cushion for her chair. A review of resident #2's Initial Weekly Wound Documentation Form, dated 8/23/19, showed resident #2's left buttock had a skin shear measuring 2.5 cm long, 1 cm wide, and .2 cm deep. Resident #2's wound was noted to not have drainage or odor. The wound edges were described as pink and rolled. The wound treatment was noted as, Apply [MEDICATION NAME] Lotion on left buttock 3 times a day with each bowel movement. A review of resident #2's Physician Order, dated 1/21/20, showed, Cleanse area of left buttock with normal saline. Apply collagen to wound bed. Cover site with hydrogel dressing. Change dressing QOD. Discontinue when healed. A review of resident #2's Braden Scale Assessments showed the following: - On 2/28/19, resident #2's assessment score was a 23, which was not at risk for developing a pressure sore. - On 6/3/19, resident #2's assessment score was a 19, which was not at risk for developing a pressure sore. - On 9/3/19, resident #2's assessment score was a 19, which continued as not being at risk for developing a pressure sore. - On 12/2/19. resident #2's assessment score was a 17, and the resident was at risk for developing a pressure sore. A review of resident #2's Skin/Wound Notes showed the following: - On 8/25/19, The left coccyx was shearing and was being treated with [MEDICATION NAME] cream. The documentation did not specify the cause of the shearing noted. - On 9/7/19, Soiled dressing removed from bilateral coccyx today, Wound to L. coccyx remains open with serosanguineous drainage and R. coccyx is very dry with pinpoint opening with serosanguineous drainage. - On 11/28/19, The weekly skin check was not noted to have any issues. - On 12/6/19, RN observed open area on left buttock and redness to right buttock. - On 12/9/19, Resident #2 had no open areas to buttocks. - On 1/1/20, Resident #2's, Bilateral coccyx continues to have irritated/scabbed skin and were cleansed today with NS, patted dry with gauze and [MEDICATION NAME] put in place for protection. Will continue to monitor. (sic) - On 1/15/20, Resident #2 had an Open area noted on residents left buttocks. Size 3 cm x .5 cm. MD notified via fax. Daughter called. No staging of resident #2's pressure ulcer was documented. - On 1/20/20, The open areas are decreasing in size and a dressing was applied. A review of resident #2's Care plan, with a revision date of 3/19/19, showed the following: - A focus for resident #2 as, My skin is intact. I am diabetic which increases my risk for developing pressure related breakdown. - A goal for resident #2 as, I want to keep my skin intact and healthy. - Interventions for resident #2 include, I want staff to monitor for any potential skin breakdown. I am able to reposition myself. I have a pressure redistributing mattress on my bed. No revisions were made to the care plan to reflect the current intervention and treatment to resident #2's current pressure sores. A request for resident #2's Medication and Treatment Administration record for the last three months was made on 1/28/20. No documentation was provided by the facility. A review of the facility's Skin Program Policy, with a revision date of 3/18/19, showed the following: - To ensure a resident who enters a facility with a pressure sore ulcer/pressure injury does not develop unless the residents clinical condition demonstrates that they were unavoidable. To provide care and services to prevent pressure ulcer development, to promote the healing of pressure ulcer/wounds development of additional pressure ulcers/wounds. - 1. On admission a baseline assessment of a resident's skin status will be completed within two hours of admission. It is recommended to repeat weekly x4. This will include a physical exam of the resident's skin, a risk assessment using a Risk Assessment tool, and a comprehensive assessment of the resident's history and physical condition. A temporary plan of care (POC) will be put into place for residents that are identified at-risk for breakdown. - 4. Nursing personnel will utilize the results of the physical exam and the Pressure Ulcer Assessment tools to determine an individualized pressure ulcer prevention program for each at-risk resident. This will include interventions to: a) Protect skin against the effects of pressure, friction, and shear; b) Protect the skin from moisture; . f) Immediate prevention plan instituted when potential areas are identified. - 7. Nursing personnel will develop a POC with interventions consistent with resident and family preferences, goals and abilities, to create an environment to the resident's adherence to the pressure ulcer prevention/treatment plan. POC to include; Impaired mobility, Pressure relief, Nutritional status and interventions. Incontinence, Skin condition checks, Treatment, Pain, Infection Education of resident and family, Possible causes for pressure ulcers and what interventions have been put in place to prevent. Skin checks are to be completed at least weekly by a Licensed Nurse. - 10. Monitoring results will be brought to the IDT workgroup (Pressure Ulcer team) who will meet to review current practices, assessment tools and schedules and to identify person(s) responsible for monitoring . |
2020-09-01 |