| 76 |
VALLE VISTA MANOR |
275021 |
402 SUMMIT AVE |
LEWISTOWN |
MT |
59457 |
2018-11-15 |
686 |
D |
0 |
1 |
MIUW11 |
Based on observation, records review, and interview, the facility failed to prevent and identify the development of a Stage II pressure ulcer, and failed to assess the progress of the pressure area for 1 (#20) of 12 sampled residents. Findings include: During an observation on 11/15/18 at 9:13 a.m., resident #20's coccyx showed evidence of a healing pressure area. Calazine was applied to the areas by staff member F. Staff member F put on gloves and opened a drawer, and applied the lotion without changing to clean gloves. Review of resident #20's progress note, dated 9/26/18, showed residents wife brought to this RN's attention that resident had a sore on his bottom. Resident does not report pain, has difficulty remembering to alert staff of needs, is incontinent at times, and prefers to sit in recliner throughout the day. The wound was assessed measuring 1.0 x. 6 x 0.2, Stage II. No intervions were implemeneted for the pressure sore, despite the above identified causes. During an observation on 11/13/18 at 11:30 a.m., resident #20 was sitting in his recliner; he did not have a pressure reducing cushion in his recliner, or on his wheelchair. During an interview on 11/15/18 at 9:13 a.m., staff member F stated the wife took the ROHO cushion for the recliner home. She did not know why. Review of a progress note dated, 11/5/18, showed the wound was closed with some scabbing. Review of the medical record showed no other assessments or measurements regarding the pressure area. Review of the Admissions MDS, with the ARD of 8/23/18, showed no pressure reducing device for the bed or chair, and no turning and reposition program. During observations on 11/13/18 at 11:35 a.m., 11/14/18 at 10:41 a.m., 11/14/18 at 1:57 p.m., and 11/15/18 at 10:26 a.m., resident #20 was sleeping in his recliner without a pressure reducing cushion, or position changes. Review of resident #20's weight report showed a significant weight loss, with no additional calories or protein to promote healing. Review of the Care Plan, dated 10/18/18, did not include the presence of a Stage II pressure sore. It showed a Braden score of 20, meaning no risk factors for the developing a pressure sore. During an interview on 11/15/18 at 12:20 p.m., NF1 stated she was not sure why resident #20 developed a pressure area, but guessed it was from not getting cleaned up adequately. During an interview on 11/15/18 at 1:08 p.m., staff member [NAME] stated she did not know why resident #20 developed a pressure area with out reviewing his chart. She stated the facility should have had an initial skin assessment report, and completed a weekly assessment until resolution of the pressure area. |
2020-09-01 |