| 97 |
ST JOHN'S LUTHERAN HOME |
275024 |
3940 RIMROCK RD |
BILLINGS |
MT |
59102 |
2017-11-08 |
314 |
D |
0 |
1 |
8YVD11 |
Based on observation, interview, and record review, the facility failed to prevent the development of two avoidable pressure ulcers, and failed to adequately investigate the cause, (with no assessed risk factors) for 1 (# 12) of 25 sampled residents. Findings include: a. Review of resident #12's Quarterly MDS, with the ARD of 8/23/17, showed the development of a Stage II pressure ulcer on the resident's buttocks, on 8/22/17. Review of resident #12's Pressure Injury Report, dated 8/22/17, showed yellow slough. Review of resident #12's Braden Scale, dated 8/30/17, showed a score of 20, meaning no risk factors for developing pressure ulcers. The resident was independent for all care needs. During an interview on 11/8/17 at 2:15 p.m., staff member G stated the pressure ulcer may have developed because resident #12 slept in his recliner. Staff member G stated the facility added a ROHO cushion to the recliner, and resident #12 was a very private man who did not always permit care. Review of resident #12's Care Plan showed as a Stage I to the gluteal cleft, 1 cm x 1 cm on the left side, and 1 cm x 1 cm on the right side. Interventions were the cushion in the recliner, and encourage elder to side lie in bed. The pressure ulcer was documented as healed on 9/18/17. During an interview on 11/8/17 at 3:00 p.m., staff member M stated the pressure ulcer did have yellow drainage and slough. He stated he did not know that slough does not occur with Stage II pressure ulcers. Staff member M stated he believed the pressure ulcer was from friction, and resident #12 needed to be greased up. During an observation and interview on 11/8/17 at 9:20 a.m., resident #10 had a skin cream at his bedside. When asked, he stated he put it on by himself, but it was better when the staff put it on. Staff member M stated it reduced the friction on his bottm. The resident was sitting in his recliner without a cushion. The cushion was next to the recliner. b. Review of resident #12's Care Plan, dated 11/5/17, showed a discoloration to the left medial/dorsal foot, 3.3 cm x 3 cm. Elder wearing regular cowboy boots per his preference. Elder advised by medical staff boots can worsen Charcot's foot and cause pressure injury. Elder often refuses to remove boots. The intervention was to leave open to air, and monitor every 24 hours. During an observation and interview with staff O on 11/8/17 at 12:40 p.m., resident #12 was sitting in his recliner, with his boots off. He stated the nurse was going to take care of the sore on his foot. His [NAME] Hose had bloody drainage on it. Staff member O came in to clean the pressure sore, and covered it with a dressing. She stated it was now a Stage II pressure ulcer, and about the size of a quarter. During an interview on 11/8/16 at 12:10 p.m., staff member H stated the area had been charted as a bruise to the foot. She stated if the boots were the cause, the area would have developed long ago. She said the facility attempts to have one nurse look at skin issues, so the same pair of eyes see the progression, but staff do not have specific wound education. |
2020-09-01 |