cms_ND: 43
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 43 | THE MEADOWS ON UNIVERSITY | 355024 | 1315 S UNIVERSITY DR | FARGO | ND | 58103 | 2018-12-06 | 684 | G | 1 | 0 | PNS511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on information provided by the complainants, observation, record review, review of professional reference, and resident/staff interviews, the facility failed to provide the necessary care/services to treat 1 of 10 sampled residents (Resident #10) with skin breakdown and pain/discomfort. Failure to monitor Resident #10's skin condition and provide physician-prescribed interventions in a timely manner contributed to her existing skin breakdown and resulted in her experiencing avoidable pain/discomfort. Findings include: Information provided by the complainants indicated facility staff failed to identify possible risk factors contributing to residents' skin conditions and failed to provide the care/services necessary to prevent further skin breakdown. The complainants reported having been contacted by residents who were frustrated waiting for staff to respond to their call lights and/or who experienced pain/discomfort secondary to skin breakdown/being soiled. The facility failed to provide a copy of their policy addressing skin conditions/pressure ulcers upon request. Kozier & Erb's Fundamentals of Nursing: Concepts, Process, and Practice, 10th ed., Pearson Education, Inc., New Jersey, pages 828 and 862, states, . Many medications increase (skin) sensitivity . [MEDICAL CONDITION] drugs [MEDICAL CONDITION] . Several factor increase the risk for the development of pressure ulcers: immobility and inactivity, inadequate nutrition, fecal and urinary incontinence . and certain chronic medical conditions. Nursing interventions to prevent the formation of pressure ulcers include conducting ongoing assessment of risk factors and skin status, providing skin care to maintain skin integrity, ensuring adequate nutrition and hydration . providing supportive devices . - Review of Resident #10's medical record occurred on all days of survey. The record identified [DIAGNOSES REDACTED]. The current physician's orders [REDACTED]. * 11/26/18, [MEDICATION NAME] (an over-the-counter skin protectant ointment) - Apply TID (three times daily) to affected gluteal, perineal, and vulvar areas. * 12/03/18, [MEDICATION NAME] 0.2% - [MEDICATION NAME] 2% in Lipovan Rectal Cream (a prescribed cream applied to relieve pain) . Apply to rectum topically BID (twice daily). Donut cushion to minimize perineal discomfort with sitting. * Undated, Monitor skin for breakdown . Q (every) shift. * Undated, Must complete all documentation for skin alterations on Saturday . A Braden Scale (a skin assessment), dated 11/19/18 (the evening of Resident #10's admission to the facility), identified, . Rarely Moist: Skin is usually dry, linen only requires changing at routine intervals . Chairfast: Ability to walk severely limited . Cannot bear own weight and/or must be assisted into chair or wheelchair. Slightly Limited (Mobility): Makes frequent though slight changes in body or extremity position independently. Adequate (Nutrition): Eats over half of most meals. Eats a total of 4 servings of protein . Occasionally will refuse a meal, but will take a supplement when offered . No Apparent Problem (Friction/Shear): Moves in bed and in chair independently and has sufficient muscle strength to lift up. It is unclear how staff determined Resident #10's skin was usually dry, her linens only required changing at routine intervals, she ate greater than 50% of most meals, ate 4 servings of protein daily, and/or occasionally refused meals. The current care plan identified the following: * . Focus: Resident is at risk for falls/injuries . Interventions: . Encourage resident to request assist whenever needed. * . Focus: Skin integrity impaired: redness to perineum area secondary to diarrhea r/t (related/to) [MEDICAL CONDITION] . Interventions: Maintaining clean, dry skin provides a barrier to infection. [NAME]ng skin dry instead of rubbing reduces risk of dermal trauma to fragile skin. Monitor for s/s (signs/symptoms) of infection . Notify MD (medical doctor) as needed. The care plan failed to reflect Resident #10's need for a physician-prescribed barrier cream and/or pressure relieving device. The progress notes identified the following: * 11/19/18, . Patient was admitted from (hospital) with a [DIAGNOSES REDACTED]. Patient has redness in groin areas and sacrum. * 11/20/18, . She uses call light for needs . * 11/22/18, . Patient is incontinent of B/B (bowel/bladder) . Assist of one for bed mobility and transfers. Patient stays in her room most of the time. * 11/25/18, Weekly skin assessment done, noted redness to her bottom and continuing with feces d/t (due/to) her illness. cleansed the area and treatment done as directed. * 11/26/18, Patient returned from (cancer center) with new orders to discontinue ammonium [MEDICATION NAME]. Start [MEDICATION NAME] to apply to gluteal/perianal and the vulvar areas three times a day. monitor skin for breakdown every shift. * 11/27/18, . Her coccyx area is excoriated from frequent diarrhea. Lac-Hydrine cream is burning her, so it will be d/c (discontinued) and [MEDICATION NAME] started. * 11/28/18, . Receiving [MEDICAL CONDITION] therapy and continuous chemo infusion for [MEDICAL CONDITION]. * 11/29/18, . Incontinent of B/B (bowel/bladder) maximum assist with all cares. Extensive assist with transfers and bed mobility. Pain management effective with Tylenol as when needed. * 11/30/18, . She is checked et (and) changed/repositioned on a routine basis. * 12/02/18, . She is routinely checked at night. Is able to direct own cares and does ask for assistance appropriately as needed. Assist with toileting needs. Assist with transfers, pt. did remain in room . resident is thin and skin intact with redness to the perirectal area do (sic) to stool, treatments and incontinences (sic) treatment to area bid and prn (as needed). * 12/03/18, Pt . is slightly confused/forgetful at times. Assist with toileting needs, is incontinent at times. Transfers with assist. Pt. does remain in room . Extensive assist with toileting needs. Patient is HOH (hard of hearing) but can make needs known. patient ask (sic) for assistance appropriately. * 12/04/18, . makes needs known to staffs (sic). Extensive assist with care and toileting needs. No new open areas noted in the button (sic) and the perineal area. Pt. does remain in room . Pain management was effective with Tylenol when needed. In the (care) conference more attention to be paid to patient care and diet. No new skin areas of concern noted by this writer after lasted (sic) treatment was done at HS (hour of sleep) this shift. Though patient is noted to have more than 3-4 bathroom trips during one shift. One assist using her walker for toileting. During an interview on 12/05/18 at 5:05 p.m., Resident #10 (identified by the facility as interviewable) stated, Last night, I sat all night in a dirty diaper. The call light was unplugged. That's a long time . all night. That's a long time to have a dirty diaper. No one was in here at all last night. Resident #10 also reported a staff member working the evening/night shift had directed her to put the cream on herself. Observation showed Resident #10 lying in bed on a pressure-guard mattress, with her wheelchair next to the bed, a square (versus donut-shaped) pressure-relief cushion in place. During an interview on 12/06/18 at 7:50 a.m., Resident #10 pointed to her call light and stated, I rang the bell here. I finally got up and went in there (bathroom). I rang the bell in there. Took them forever. About twenty-five minutes, I was sitting there this morning. She then repeated her concern regarding the evening/night shift staff member who directed her to put the cream on herself. Observation showed Resident #10 lying in bed, squirming from side to side. When asked if she required assistance, she pointed towards her buttocks and stated, It itches. Then it hurts. It's irritated. It hurts so bad! A different med (medication) is coming from Pharmacy today. During an interview on 12/06/18 at 10:50 a.m., Resident #10 shifted her weight as she laid on the bed and stated, My butt is so sore! The girls are getting so disgusted checking my diaper. I hate to do it (points towards call light). During an interview on 12/06/18 at 10:55 a.m., when asked questions pertaining to Resident #10's toileting needs, a CNA (#4) stated Resident #10 puts on (her) call light. If we're helping someone else, she will self-transfer to (the) bathroom. When we provide toilet cares, (we) gently wipe (the) little sore on her buttocks. Just redness to her buttocks, but very painful! Put a little ointment on the rash. The CNA then showed the surveyor the tube of Peri-Guard ointment located in Resident #10's dresser drawer. The CNA (#4) also reported offering to assist Resident #10 to the bathroom if needed. Observation showed no personal cares or assistance to the bathroom from 7:50 a.m. and 10:55 a.m. When asked questions pertaining to the progress notes referencing changing and/or routinely repositioning Resident #10, the CNA (#4) reported staff chart at the end of their shift. She confirmed staff are not required to chart after each interaction. Observation on 12/06/18 at 12:48 p.m., showed a CNA (#4) assisted Resident #10 into the bathroom and provided toileting cares. Resident #10's coccyx appeared darkened, and her perineal/rectal area appeared reddened/raw-looking. Resident #10 voiced discomfort when the CNA (#4) applied Peri-Guard ointment to the reddened area. During an interview on 12/06/18 at 1:30 p.m., when asked questions pertaining to Resident #10's prescribed skin cream, an administrative nurse (#1) reported the facility received the physician's orders [REDACTED]. The nurse (#1) explained the pharmacy did not have that particular cream in stock and therefore contacted a second pharmacy to see if they had it in their inventory. The administrative nurse (#1) reported the Pharmacy delivered the cream on 12/05/18. Review of the Medication Administration Record [REDACTED]. When asked questions regarding the discrepancy, the administrative nurse (#1) stated, It (Lipovan rectal cream) may have hit the building late in the day. It should have been here (12/03/18). Staff should have called (her physician) that evening, and checked into another medication until it came in. During an interview on 12/06/18 at 3:40 p.m., an administrative nurse (#1) reported the facility currently does not have a policy regarding skin issues/pressure ulcers. The administrative nurse (#1) then stated he would expect nursing staff to complete the Braden Scale upon admission, weekly for three weeks, and every three months thereafter. After identifying Resident #10 as having [MEDICAL CONDITION] and skin breakdown, the facility failed to: * Develop a policy outlining staff expectations for providing skin care, * Identify the risk factors impacting Resident #10's ability to heal, including her need for high calorie foods/supplementation, prompt transfer/toileting assistance following each episode of incontinence, and a physician-prescribed barrier cream/pressure relieving device, * Accurately document Resident #10's baseline risk factors for developing a facility-acquired pressure ulcer, * Continue to monitor Resident #10's skin until they were able to determine no concerns existed for the development of a facility-acquired pressure ulcer, * Care plan Resident #10's need for a physician-prescribed barrier cream and specific pressure relieving device, and/or * Provide the care/services necessary to prevent further skin breakdown and/or avoidable pain/discomfort; including scheduled and/or prompt transfer/toileting assistance, Lipovan rectal cream, donut cushion, etc. See F565 and F692. | 2020-09-01 |