cms_ND: 4
Data source: Big Local News · About: big-local-datasette
| rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 4 | THE MEADOWS ON UNIVERSITY | 355024 | 1315 S UNIVERSITY DR | FARGO | ND | 58103 | 2017-05-10 | 314 | D | 1 | 1 | ZMNB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review, and staff interviews, the facility failed to provide appropriate interventions and treatment to promote healing for 1 of 2 sampled residents (Resident #7) with a current pressure ulcer. Failure to provide timely and appropriate interventions and ensure staff consistently implemented those interventions resulted in further deterioration of Resident #7's existing pressure ulcer. Findings include: Review of Resident #7's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS), dated [DATE], identified severely impaired cognition, at risk for pressure ulcers, and extensive assistance of two or more persons for bed mobility. Resident #7's current care plan stated, . Focus At risk for alteration in skin integrity related to: . impaired mobility. Encourage to reposition as needed; use assistive devices as needed. Observe skin condition . report abnormalities. Focus deep purple tissue injury on left heel . Administer treatment per physician orders [REDACTED]. Resident #7's current certified nursing assistant (CNA) kardex stated, . SKIN CARE encourage and/or assist to reposition frequently. HEEL PROTECTOR-left foot. SUSPEND HEELS . The nurse practitioner progress note, dated 03/24/17, stated . CHIEF COMPLAINT: complaints of pain in left heel . OBSERVATIONS: . approximately 4 cm (centimeter) round purplish area on left heel that is not blanchable. Diagnosis: [REDACTED]. boots (heel protector) on, when she is in bed she will have her heels floated so nothing is touching them. We'll continue to follow closely. If wound worsens will send her to wound clinic. The progress notes identified the following: * 03/22/17, Deep purple area 4 x (by) 3 cm. Surrounding purple area is red, . * 03/24/17, Wound rounds: Deep purple and not blanchable measuring 4 x 3 cm. The progress's notes showed the nursing staff failed to notify the physician when the wound size increased. * 04/07/17, . Left heel has deep purple tissue injury to left heel measuring 6 x 4 cm. Skin around is blanchable. * 04/14/17, . Patient has deep purple tissue injury to left heel measuring 6 x 3 cm. Surrounding skin is light purple in color and blanchable. * 05/05/17, . Deep purple discoloration still to left heel measuring 6 x 2.5 cm. Observations showed the following: * 05/08/17 at 12:45 p.m., Resident #7 sat in her reclining wheel chair in the dining room with gripper slippers on both feet. The left heel rested directly against the foot board. The staff failed to place the heel protector boot on the left foot. * 05/08/17 at 4:40 p.m., Resident #7 sat in her reclining wheel chair and the CNA (#4) placed the heel protector boot on the right foot. The left heel rested directly against the foot board. The CNA placed the heel protector boot on the wrong foot. * 05/09/17 at 7:45 a.m., 8:30 a.m., 9:45 a.m. and 10:50 a.m., Resident #7 sat in her reclining wheel chair in her room with the heel protector boot located on a chair in her room. The left heel rested directly against the foot board. The staff failed to place the heel protector boot on the left foot. During an interview on 05/10/17 at 11:35 a.m. and 3:30 p.m., an administrative staff member (#1) confirmed Resident #7's deep tissue injury is from failure to off load the heel. The nurse manager should complete a weekly assessment on Resident #7's heel. | 2020-09-01 |