| 54 |
MINOT HEALTH AND REHAB, LLC |
355031 |
600 S MAIN ST |
MINOT |
ND |
58701 |
2019-06-11 |
684 |
D |
1 |
0 |
HFFF11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > THIS IS A REPEAT DEFICIENCY FROM SURVEYS COMPLETED ON 08/16/18. AREAS OF SKIN BREAKDOWN 1. Based on information received from the complainants, record review, review of facility policy, and staff interview, the facility failed to provide the necessary care and services to prevent the development and promote healing of skin breakdown for 2 of 4 sampled residents (Resident #13 and #15) and 1 discharged resident (Resident #18) at risk of developing or with known abrasions, skin tears, and burns. Failure to reassess and/or consistently utilize interventions contributed to Resident #13, #15, and #18 developing new wounds and/or healing of their various areas of skin breakdown. Findings include: Information provided by the complainants indicated nursing staff failed to consistently utilize physician ordered interventions to prevent and/or heal areas of skin breakdown. Review of the facility policy titled Skin Management System occurred on 06/10/19. This undated policy stated, . Pressure Ulcers, Venous Ulcers, and Arterial Ulcers, and surgical sites will be documented on . form or EMR (electronic medical record). Use one form per wound. Wound progress is to be documented each week with measurement and wound descriptions. Daily treatments are also documented on the same form. Skin issues such as skin tears, bruises, rashes, abrasions,[MEDICAL CONDITION]. will be documented . - Review of Resident #13's medical record occurred on all days of survey. The current physicians order stated the following: * Started 05/21/19, . Clean area to right clavicle with NS (normal saline), apply triple antibiotic cream and cover with [MEDICATION NAME] every day shift . * Started 05/25/19, . Clean large skin tear to RFA (right forearm) with NS and applied antibiotic ointment and xeroform gauze, cover with boarder foam gauze. Clean small skin tear to RFA with NS and apply paper tape. Change Q (every) 3 days until healed . A progress note, dated 05/23/19 at 3:30 p.m., stated . CNA (certified nursing assistant) alerted nurse to a large skin tear to rt (right) inner elbow area . 7cm (centimeters) x 2cm wide skin tear unable to approximate, is open area bright red wound bed, no active bleeding noted, edges of wound dried looking. Also has a small 1 cm x 1cm skin tear on rt forearm . Review of Resident #13's progress notes and skin/wound assessments identified the facility failed to document weekly on the progress of the skin including measurements and descriptions. Nurses' notes and wound assessments stated the following: * 05/18/19 - Abrasion measuring 1.0 cm x 1.5 cm on right clavicle area * 05/20/19 at 10:00 p.m. - Abrasion on right clavicle is small and superficial * 05/25/19 - Abrasion measuring 1.0 cm x 1.5 cm on right clavicle area Review of progress notes and skin/wound assessments identifies the facility failed to document weekly on the progress of the skin including measurements and descriptions. - Review of Resident #15's medical record occurred on all days of survey. The current physicians order stated, . Skin evaluations weekly . Nurses' notes and wound assessments stated the following: * 01/18/19 at 10:34 a.m. - . Skin is intact. Potential for skin breakdown due to limited mobility . * 01/23/19 - Has 2 skin tears on her left leg, well approximated cleaned with NS, applied triple antibiotic and covered with appropriate dressing. Resident did not know what had happened * 01/24/19 - Skin tears noted to the left lower leg, cover with tape, redness around the area * 02/07/19 - Skin intact * 02/14/19 - Skin intact * 02/20/19 at 7:37 a.m. - . notification of skin tear to left lateral calf of resident. Family is concerned that resident may have attempted independent transfer to the toilet as this is what has been observed in the past. Informed that resident will be monitored for safety and care staff will provide ADL assist. * 02/21/19 - Skin tear on left lower leg measuring 10 cm x 2 cm x 0.1 cm with bordered gauze and non-adherent dressing applied. Change daily after cleaning with NS and PRN (as needed). * 02/28/19 - Skin tear covered * 03/08/19 10:38 a.m. - Area to lower left extremity still not healed . * 03/13/19 at 10:34 a.m. - Writer noted a new skin tear to left lower leg, above present one, measuring 1cm x 1.2cm. Writer asked resident what happened, she stated well I don't know. Area was cleaned with normal saline, sterile boarder gauze dressing applied . * 03/28/29 - Skin tear * 04/11/19 - Healing to pre-existing skin tear to left lower leg * 04/18/19 - Skin intact * 04/18/19 7:44 p.m. - . left lower leg . Area is now healed . Review of progress notes and skin/wound assessments identifies the facility failed to document weekly on the progress of the skin including measurements, description, and identify the date the skin areas had healed. - Review of Resident #18's medical record occurred on all days of survey, and identified [DIAGNOSES REDACTED]. RIGHT LOWER LEG The Admission Evaluation, dated 07/07/18, identified, . 6.5 x 6 cm [MEDICAL CONDITION] sore to the front of the right lower leg and 2 x 1 cm [MEDICAL CONDITION] sore to the front/2.2 x 2 cm [MEDICAL CONDITION] sore to the back of the left lower leg . Resident #18's care plan identified, . Date Initiated: 07/07/18 . Scabbed areas at (bilateral lower extremeties) r/t (related to) recent [MEDICAL CONDITION] treatment . Encourage and assist as needed to turn and reposition, use assistive devices as needed, Follow up care with MD (medical doctor) as ordered, Report evidence of infection such as purulent drainage, swelling, localized heat, increased pain, etc. Notify MD PRN, Use pillows and/or positioning devices as needed . The orders identified the following: * Start Date 07/14/18, . Skin evaluation weekly on Saturday Days - complete weekly skin review under assessments one time a day every Sat (Saturday) . The facility failed to perform this task on a weekly basis. * Start Date 07/27/18, . Keep area to right lower extremity clean and dry. (MONTH) use soap/water, enxymatic (sic) cleanser, or saline washes as needed. (MONTH) use non-stick dressing/[MEDICATION NAME] if area oozes or bleeds temporarily. DO NOT routinely apply lotion or cream. as needed Resident #18's progress notes identified the following: * 07/30/18 at 12:56 p.m., Resident continues with dry area of [MEDICAL CONDITION] on her right shin . * 08/28/18 at 4:39 p.m., New order received to swab and culture wound to RLE (right lower extremity) to R/O (rule out)[MEDICAL CONDITION] (antibiotic resistant organism) and Wound care Nurse to follow for possible debridement. The facility failed to reassess the wound since it was first identified on 07/07/18. * 08/30/18 at 5:00 p.m., . call to (Physician) . due to preliminary report on wound culture and extensive bacteria present . resident's decreased tolerance with physical therapy over the past few days, and malodorous smell from wound bed . requests to send patient to ED (emergency department) for further workup due to concerns of systemic infection . and at 7:38 p.m., . returned back into facility . Received new orders saline wet to dry dressing daily . continue the Batruim (sic) DS . should be effective in treating her infection to her open wound to lower right extremities . * 09/01/18 at 4:27 p.m., Dressing to Right lower extremity changed using wet to dry with NS. Wound bed is tan with slough. A nickle (sic) sized scab came of (sic) with dressing, no bleeding present. * 09/03/18 at 9:59 a.m., . Dressing to Right lower leg . no drainage noted. The only weekly skin review provided by the facility, dated 09/03/18, identified, . left lower buttock . site with dressing. Right mid-lower leg wound with wet to dry dressing changed daily. Resident #18's progress notes also identified: * 09/05/18 at 10:31 a.m., Wound to Right lower leg has wet to dry dressing. Wound looks to be healing and getting smaller in size, no drainage noted. * 09/08/18 at 6:48 p.m., . dressing to rt leg . no active drainage noted, no signs of infection noted. * 09/09/18 at 12:42 p.m., . dressing changed, wet to dry applied . * 09/14/18 at 10:58 a.m., Wound to Right to lower anterior leg appears to be healing, it is getting smaller in size . and at 3:59 p.m., Dressing to Right lower leg changed . Wound is 7 x (times) 6 cm in diameter. NO drainage noted. The facility failed to measure the wound since it was first identified on 07/07/18. * 09/19/18 at 6:27 p.m., . Dressing to Right lower leg changed using [MEDICATION NAME] and [MEDICATION NAME]. The orders identified, Start Date 09/26/18, . Cleanse RLE with NS, pat dry, apply [MEDICATION NAME] AG, wrap with kerlix, change daily, one time a day for Wound care . The facility failed to perform this task on a daily basis. Progress notes also identified: * 10/03/18 at 7:09 p.m., This nurse informed (Physician's) clinic that right lower leg does not improve with the current dressing management . stated we can do the Dakins Half Strength 0.25% topical solution, apply to right lower leg open wound BID (twice daily) wet to dry dressing x 1 week. * 10/08/18 at 7:17 p.m., Received orders . discontinue dakins, apply Santyl to right lower leg wound Q (every) 12 hrs (hours) until appointment with vascular surgeon . cover with gauze and Kerlix . The orders identified the following: * Start Date 10/09/18, . Apply santyl to right lower leg every 12 hours two times a day related to unspecified open wound, right lower leg . until 10/23/18 . Cover with gauze and kerlix . Follow up with vascular surgeon . The facility failed to perform this task on a daily basis. The Medication Administration Record [REDACTED] * Start Date 10/08/18, . [MEDICATION NAME] 500 mg (milligrams) PO (by mouth) every 24 hrs (hours) for 10 days. The chart showed staff administered six doses of the antibiotic. (The tenth dose was due the day after she was discharged from the facility.) The progress note, dated 10/09/18 at 10:30 p.m., identified, Resident started first dose of [MEDICATION NAME] tonight. Wound to right lower leg has yellow slough present in wound bed. Wound has purulent yellow drainage that is soaked onto the kerlix covering her legs. Wound has an odor to it. Dressing changed . The physician placed Resident #18 on an antibiotic six days after staff first noted her leg was not improving under the current treatment program. The care plan identified, . Date Initiated: 10/10/18 . Infection of wound/skin . Administer meds as ordered, Record temperature as clinically indicated . The progress notes also identified the following: * 10/12/18 at 10:00 p.m., . taking [MEDICATION NAME] . Wound has a fishy smell to it. Wound has yellow sloth throughout it with purulent yellow drainage. Resident states it is painful when doing dressing changes. Wound . dressed in santyl cream, guaze and kerlix . Will continue to monitor. * 10/14/18 at 12:25 p.m., . on [MEDICATION NAME] . Some yellow drainage noted. Drsg (dressing) changed . * 10/15/18 at 1:00 a.m., . continues taking [MEDICATION NAME] . Dressing changed . Scant amount of yellow slough in middle of wound bed. Also had scant amount of yellow drainage noted on old dressing. The facility failed to measure the wound since it was first identified on 09/14/18. * 10/16/18 at 9:10 p.m., . transport to . (another facility out of state) . LEFT LOWER BUTT[NAME]KS Resident #18's care plan identified, . Date Initiated: 07/07/18 . Administer treatment per MD orders, Encourage and assist as needed to turn and reposition, use assistive devices as needed, Follow up care with MD as ordered, Report evidence of infection such as purulent drainage, swelling. Localized heat, increased pain, etc. Notify MD PRN, Toileting program as indicated. The progress notes identified the following: * 08/02/18 at 3:38 p.m., Resident has a firm area to the left lower buttock, it is not raised, it has no discoloration, resident states it is very painful when palpated, (Physician) called . * 08/03/18 at 7:36 p.m., Assessed area to left buttock. Area not raised but more of a moveable nodule. Patient unable to differentiate pain from this side versus the other side at this time. This area is the same in color as the other side on examination. We will continue to monitor and contact the MD if necessary. Patient does have an appointment scheduled on Tuesday . * 08/06/18 at 2:39 p.m., . continues with hardened area to her left buttock, she states it hurts only when palpated, it is with no change in color, resident has appointment tomorrow . * 08/07/18 at 5:49 p.m., . (Physician) findings were: Left buttocks mass, no [MEDICAL CONDITION]. New order was to get ultrasound. * 08/14/18 at 4:37 p.m., . ultrasound done on Monday. states that she (has) discomfort when she is seated. Left buttock has no discoloration/no redness, no swelling but has a palpable and movable mass, no warmth noted. * 08/27/18 at 4:00 p.m., Patient had an Incision and Drainage done at (Hospital) by (Physician), with the following orders: Bactrim DS 800 mg-160 mg oral tab 1 tab PO BID x 7 days, [MEDICATION NAME] 5 mg-325 mg (milligram) po tab 1 tab PO (by mouth) Q (every) 4 hr (hour) PRN for pain, Also, to change left buttock dressing daily, pack with 1/4 [MEDICATION NAME], cover with gauze and tape. * 09/01/18 at 4:27 p.m., . Incision to Left lower buttock packed with approximately 3 CM of Iodaform gauze, wet with NS and dry gauze. * 09/05/18 at 10:31 a.m., . Incision to Left lower buttock packed with about 2 cm Iodaform and wet to dry using NS. NO drainage noted. * 10/03/18 at 7:09 p.m., This nurse . asked for an order to D/C (discontinue) the current dressing on resident's left buttock area. stated we can do the Dakins Half Strength 0.25% topical solution, apply to right lower leg open wound BID wet to dry dressing x 1 week. The chart lacked assessment of the wound since it was first identified on 09/05/18. * 10/16/18 at 9:10 p.m., . transport to . (another facility out of state) . During an interview on 06/06/19 at 8:00 a.m., when asked questions pertaining to the facility's care expectations, the managerial nurse (#5) stated, What (staff) were supposed to do was complete a weekly wound tracker. The weekly skin assessment would catch any other type of skin issue, non-pressure sore. so we know it's there. The facility failed to: * Accurately identify/document observations of Resident #18's [MEDICAL CONDITION] sore on her leg and mass on her buttocks, * Administer medications as per physician's order, * Treat Resident #18's infected leg sore and buttock mass in a timely manner, * Treat Resident #18's infected leg sore and buttock mass as per physician's order, and * Measure Resident #18's the [MEDICAL CONDITION] sore and mass in a timely manner/weekly per facility policy. BLOOD SUGAR PARAMETERS 2. Based on information received from the complainants, record review, and review of professional reference, the facility failed to establish individualized blood glucose parameters for 1 of 1 resident discharged from the facility (Resident #17) who experienced repeated hypoglycemic (low blood sugar) episodes. Failure to establish high/low blood glucose parameters has the potential to place all diabetic residents at risk for serious adverse events. Findings include: Information provided by the complainants indicated nursing staff failed to provide care/services to a resident who experienced a hypoglycemic episode and failed to communicate information regarding the resident's condition to other staff members. Review of the American Diabetes Association website occurred on 06/10/19. The article entitled, Glycemic targets: Standards of Medical Care in Diabetes - 2019 stated, . Glucose monitoring allows patients to evaluate their individual response to therapy and assess whether glycemic targets are being safely achieved. Integrating results into diabetes management can be a useful tool for . preventing [DIAGNOSES REDACTED], and adjusting medications . Level 1 [DIAGNOSES REDACTED] is defined as a measurable glucose concentration - Review of Resident #17's medical record occurred on all days of survey and identified [DIAGNOSES REDACTED]. The physician's orders identified Resident #17 received the following: * [MEDICATION NAME] injections three times daily per sliding scale with meals * 100 mg [MEDICATION NAME] daily * 100 unit/ml [MEDICATION NAME] twice daily, and * 1000 mg [MEDICATION NAME] twice daily. The care plan identified, Endocrine system r/t (related to) insulin dependent diabetes . Obtain glucometer readings and report abnormalities as ordered . Report symptoms of [DIAGNOSES REDACTED]: weakness, pallor, diaphoresis, vision changes, change in consciousness. The progress notes identified the following: * 03/31/19 at 11:50 a.m., Will update family and MD (physician): Resident was hypoglycemic with a blood sugar of 52 mg/dl (Level 2 [DIAGNOSES REDACTED]). She was non verbal, clammy and lethargic. [MEDICATION NAME] administered by this nurse, ambulance called. When ambulance crew arrived, resident sugar level was up to 60 mg/dl (Level 1 [DIAGNOSES REDACTED]). Her vitals was (sic) stable, she verbally refused going to the hospital . It's unclear who ordered the [MEDICATION NAME]. The chart lacked evidence staff informed Resident #17's primary physician of her hypoglycemic episode. * 05/02/19 at 5:45 p.m., Resident is pale (and) diaphoretic. Blood glucose is 52 mg/dl (Level 2 [DIAGNOSES REDACTED]). No emisis or c/o (complained of) nausea. (Physician) on call . paged (and) gave new order to administer [MEDICATION NAME] 1 mg intramuscularly now (and) recheck blood glucose in 15 minutes. Order observed. The chart lacked evidence staff informed Resident #17's primary physician of her hypoglycemic episode. * 05/03/19 at 1:14 a.m., Resident was found pale, diaphoretic and unresponsive (symptoms of Level 3 [DIAGNOSES REDACTED]). Unresponsive to sternum rub. BS (blood sugar) was 35 (Level 2 [DIAGNOSES REDACTED]). [MEDICATION NAME] 1 mg given. 15 mins later, resident continued to be unresponsive and pale. Her BS was 44. Another [MEDICATION NAME] 1 mg injected. 15 mins later her BS was 85. Nurse gave another sternum rub and resident pushed away hands. (Physician) whom is taking call . gave order to administer the [MEDICATION NAME] 1 mg x (times) 2. Primary MD will be notified via fax. The chart lacked evidence staff informed Resident #17's primary physician of her hypoglycemic episode. * 05/03/19 at 2:34 p.m., Resident had a blood sugar of 32 mg/dl (Level 2 [DIAGNOSES REDACTED] with symptoms of Level 3 [DIAGNOSES REDACTED]) this morning. Called the on-call Doctor . Emergency [MEDICATION NAME] was administered on Right deltoid. Check glucose level 15 min (minutes) later and went up to 78 mg/dl. He gave an order to put and (sic) IV (intravenously) and give fluids . This nurse tried to insert . IV twice but was not able to get it. Called ambulance and they came an (sic) inserted a 22 gauge (IV) on her right arm. Immediately started fluids. Resident became alert and responsive. Called (Primary Physician) and informed him of residents current status. * 05/05/19 at 5:00 p.m., Resident was found unresponsive (symptom of Level 3 [DIAGNOSES REDACTED]) to sternum rub. BS was 67 mg/dL . [MEDICATION NAME] 1 mg given. Blood sugar rechecked 15 mins later was 106. Resident was responsive . Informed (Physician) on call . and he ordered to decrease dosage of [MEDICATION NAME] . The Primary MD will be notified . It's unclear who ordered the [MEDICATION NAME]. The chart lacked evidence staff informed Resident #17's primary physician of her hypoglycemic episode. During an interview on 06/05/19 at 3:00 p.m., a managerial nurse (#5) confirmed the facility failed to consistently notify Resident #17's primary physician of her hypoglycemic episodes and failed to obtain blood glucose parameters from her physician identifying when he should be notified of her condition. Failure to establish individualized parameters to treat low blood glucose levels for unresponsive residents has the potential to place residents at risk of developing a life-threatening hypoglycemic reaction. |
2020-09-01 |