cms_OR: 90
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| rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 90 | AVAMERE HEALTH SERVICES OF ROGUE VALLEY | 385024 | 625 STEVENS STREET | MEDFORD | OR | 97504 | 2019-06-20 | 686 | G | 1 | 0 | 90J611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review it was determined the facility failed to implement, follow and maintain pressure ulcer treatments for 3 of 4 sampled residents (#15, 20 and 23) reviewed for pressure ulcers. Resident 20 admitted to the facility with a DTI (deep tissue injury) to the coccyx (tailbone), and the treatment was not implemented timely resulting in a worsening of the pressure ulcer wound. Findings include: 1. Resident 20 admitted to the facility in 4/2019 with [DIAGNOSES REDACTED]. In an interview on 5/21/19 at 11:06 AM Witness 19 (Complainant) stated he was in the building often to check on Resident 20 and it was difficult finding staff for assistance. He felt Resident 20 was not repositioned enough, had to wait longer than 20 minutes before getting her/his brief changed and the brief would often be soaked. Witness 19 stated the wound on the resident's bottom got worse as a result. A 4/29/19 Admission Nursing Data Base indicated a dark blanchable spot to the coccyx, measuring 0.5 cm x 0.5 cm with shearing to the crease. A 5/7/19 Pressure Ulcer CAA indicated Resident 20 admitted with a DTI to her/his coccyx, she/he was at risk for skin breakdown related to urinary incontinence, decreased mobility and diabetes. The resident required extensive assist of two staff with bed mobility. Preventative measures were in place to protect the resident's skin. The coccyx wound was being monitored by nursing. A Skin and Wound Evaluation Dated 5/14/19 indicated an unstageable (obscured full-thickness skin and tissue loss) pressure ulcer with slough (dead tissue) and eschar (dry, dark scab) to the sacrum. The wound was present upon admission. Wound measurements were 4.6 cm x 3.2 cm x 0.3 cm, the wound bed was 20 percent granulation, 60 percent slough and 20 percent eschar. A moderate amount of serous (pale yellow fluid) exudate (fluid) was noted. The resident was noted to have intermittent pain. Additional notes indicated suspected DTI upon admission opened to reveal a Stage 3 (full thickness tissue loss, slough may be present but does not obscure the depth to tissue loss). A skin and Wound Evaluation was not completed until 15 days after Resident 20 admitted to the facility. A Skin and Wound Evaluation dated 5/21/19 indicated an unstageable pressure ulcer with slough and eschar. Wound measurements were 3.3 cm x 2.5 cm x 0.5 cm. The wound bed had 60 percent granulation, 30 percent slough and 10 percent eschar. There was evidence of infection with increased drainage, a moderate amount of exudate, and [MEDICAL CONDITION] (a mixture of serum and pus). Odor was moderate after cleansing. The resident was noted to have intermittent pain. Additional notes indicated a moderate purulent odor after cleansing the wound when performing the weekly wound assessment. The provider was notified and a new order was placed for Keflex (antibiotic). Resident 20 was referred to a wound center. A 5/2019 TAR instructed staff to complete the following treatment to the coccyx: - Order date of 5/13/19 directed staff to cleanse pressure wound to the coccyx with wound cleanser place calcium alginate (an absorbent wound dressing) to the wound bed and cover with a [MEDICATION NAME] (a moist dressing/bandage)every three days on day shift with a discontinue date of 5/14/19. -The treatment was not completed until 5/14/19 and no treatment was in place until 15 days after Resident 20 admitted to the facility. On 6/5/19 at 1:19 PM Staff 11 (RNCM) acknowledged no wound orders, treatments or weekly skin wound evaluations were in place for Resident 20 until 5/14/19 (15 days after the resident admitted to the facility). She acknowledged the wound worsened since the residents admission. She further stated Staff 15 (LPN) should have put an order in for the treatment of [REDACTED]. 2. Resident 15 admitted to the facility in 4/2019 with [DIAGNOSES REDACTED]. a. A 4/19/19 Admissions MDS revealed Resident 15 was at risk for pressure ulcers and she/he did not have any wounds. Interventions included a pressure relieving device for the chair and the bed. A 5/1/19 Skin Impairment investigation revealed Resident 15 was found to have an open area to the coccyx that reached both the left and right buttocks. The scabbed shearing was a 2 x 7 area which appeared to be nearly resolved with a small area of bloody drainage to the left buttocks, the bed pan was changed to a fracture pana (shallow vessel used for defecation or urination by patients confined to bed). A 5/2019 TAR instructed staff to complete the following treatments to the bilateral buttocks/coccyx: -Order date of 5/2/19 monitor healing every shift and report signs and symptoms of infection or worsening with a discontinue date of 5/8/19. -Order date of 5/8/19 cleanse shear wound with wound cleanser and cover with foam dressing. No treatments were completed as resident was out of the facility on 5/9/19. A 5/8/19 Skin and Wound Evaluation revealed Resident 15 had a facility aquired unstageable pressure ulcer to the coccyx with a start date of 5/1/19 covering an area of 9.4 square cm. Measurements were 6 cm length x 4.4 cm width x .3 cm depth, with slough (a layer or mass of dead tissue). Notes stated it was likely due to a shear injury from using a slide-board to transfer the resident. No documentation was found in the clinical records an assessment was completed for the skin impairment before 5/8/19 by an RN. On 6/5/19 at 10:43 AM Staff 11 (RNCM) stated she would look for additional information on the wound. On 6/11/19 at 7:17 AM Staff 1 (Administrator) stated there were discrepancies in the wound description and the first staff member who described the wound was an LPN, who was not authorized to stage pressure ulcers. b. A 5/1/19 Skin Impairment investigation revealed Resident 15 was found to have an open area to the coccyx that reached both the left and right buttocks. The 5/7/19 notes described the wounds as scabbed shearing with a 2.0 x 7.0 area which appeared to be nearly resolved with a small area of bloody drainage to the left buttocks. On 6/5/19 at 10:40 AM Staff 11 (RNCM) stated the investigation was completed on 5/7/19 and she would expect an investigation to be completed within five days of the start of the investigation. 3. Resident 23 was admitted to the facility in 8/2016 with [DIAGNOSES REDACTED]. a. A 3/20/19 physician progress notes [REDACTED]. A 4/26/19 Physician order [REDACTED]. A 4/2019 TAR instructed staff to cleanse the coccyx wound, apply skin prep and medicated gel then cover with foam dressing every day shift every other day. On 4/27/19 the treatment was not completed. A 5/2019 TAR instructed staff to cleanse the coccyx with wound cleanser, apply collagen to the wound base then cover with foam dressing every day shift every other day with a order date of 4/29/19. On 5/5/19 the treatment was not completed. On 6/5/19 at 10:49 AM Staff 11 (RNCM) stated she would expect staff to complete the treatment as physician ordered. b. A 3/20/19 physician progress notes [REDACTED]. A 4/7/19 physician order [REDACTED]. A 4/12/19 Skin and Wound Evaluation revealed Resident 23 had a facility acquired Stage 2 pressure ulcer to the left heel with an area of 6.4 square cm and measurements of x 3.5 cm length x 2.6 cm width x .2 cm depth with 40 percent granulation (new tissue), 50 percent slough (dead tissue) and 10 percent eschar (cast off dead tissue). A 4/2019 TAR instructed staff to cleanse the left heel with wound cleanser, apply medicated gel and cover with foam dressing every day shift every other day, with an order date of 4/5/19. On 4/9/19 the TAR indicated to refer to nurses notes. On 4/18/19 the treatment was not completed to the left heel. A 4/9/19 Nurses Note revealed Resident 23 was not in her/his room. No documentation was found in clinical records Resident 23 received physician ordered treatment to her/his left heel on 4/9/19 and 4/18/19. On 6/5/19 at 10:49 AM Staff 11 (RNCM) stated she would expect staff to complete the treatment as physician ordered. Multiple attempts should be completed for wound care and if missed the physician should be notified. c. A 3/20/19 physician progress notes [REDACTED]. No documentation was found in clinical records Resident 23's Stage 2 pressure ulcer was investigated within the five days as per policy. On 6/5/19 at 10:54 AM Staff 11 (RNCM) confirmed the investigation was not completed within the five days as per policy. On 6/11/19 at 7:17 AM Staff 1 (Administrator) stated on 2/7/19 nursing identified redness present on the buttocks. On 3/20/19 nursing staff were unaware an incident report needed to be completed due to the affected area still was closed. d. A 3/20/19 Skin Impairment revealed upon assessment by the physician Resident 23 was found to have a suspected deep tissue injury on her/his left heel measuring 4 cm by 2.2 cm by unknown depth. Notes dated 6/3/19 included in the investigation revealed on 4/2/19 there was an open area to the left heel. On 4/5/19 the RNCM assessed the wound and a new order for routine wound care implemented. Abuse and neglect was not substantiated. On 6/5/19 at 10:54 AM Staff 11 (RNCM) confirmed the investigation was not completed within the five days as per policy. e. A 3/14/19 Admissions MDS revealed Resident 23 was at risk of developing a pressure ulcer, did not have a pressure ulcer with interventions of pressure reducing device for the chair and the bed. A 3/20/19 physician progress notes [REDACTED]. A 4/26/19 physician order [REDACTED]. A review of the resident's clinical record revealed no explanation, root cause analysis or investigation related to the development of the Stage 2 pressure ulcer identified on 3/20/19 to rule out abuse or neglect. On 6/11/19 at 7:17 AM Staff 1 (Administrator) stated on 2/7/19 nursing identified redness present on the buttocks. On 3/20/19 nursing staff were unaware an incident report needed to be completed due to the affected area still was closed. | 2020-09-01 |