| 85 |
OAK HILL HEALTH & REHABILITATION CENTER |
415027 |
544 PLEASANT STREET |
PAWTUCKET |
RI |
2860 |
2017-12-20 |
686 |
J |
1 |
0 |
MUG111 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to provide necessary treatment and services, consistent with professional standards of practice, to promote healing and prevent new ulcers from developing for 2 of 7 residents who triggered an investigation for the risk of developing pressure ulcers or who have actual pressure ulcers (ID #s 2 and 85). Findings are as follows: 1. Resident ID #2 was admitted on [DATE] with [DIAGNOSES REDACTED]. Record review revealed a Braden Scale for Predicting Pressure Ulcers on 12/06/2017 which assessed the resident as at high risk for pressure. Record review for resident ID #2 revealed an admission assessment dated [DATE] which revealed that the resident has a pressure ulcer to the coccyx. There was no documentation of the size, exudate (wound drainage), pain, and description of wound bed and wound edges. Review of the resident's progress notes revealed a physician admission note dated 11/24/2017 which indicates the resident had a Stage 2 pressure ulcer (partial thickness loss of dermis (skin) presenting as a shallow open ulcer with a red/pink wound bed, without slough) to the coccyx. Additional record review revealed a physician's orders [REDACTED]. 1/4 side rails to both sides of bed which is medically appropriate to increase bed mobility and positioning. Further record review revealed a Physical Therapy progress note dated 11/24/2017 stating, patient requires bed 1/4 siderails for bed mobility and transfers in and out of bed. Observations on the following dates and times revealed no evidence of 1/4 side rails on the resident's bed: - 12/13/17 10:20 AM - 12/14/17 08:36 AM - 12/15/17 02:50 PM - 12/18/17 10:16 AM - 12/18/17 01:21 PM During a surveyor interview with the Physical Therapist, Staff G, on 12/18/2017 at 10:17 AM he stated that 1/4 side rails may help to reduce skin breakdown as it can help to shift pressure when used for positioning and/or mobility purposes. Additionally, the resident has a care plan initiated on 11/30/2017 stating that the resident is at risk for pressure ulcer development with an intervention to monitor nutritional status. The facility failed to follow the resident's plan of care to monitor nutritional status and physician's orders [REDACTED]. Refer to F-692. Record review of the resident's care plan dated 11/23/2017 reveals a care plan for alteration in skin integrity related to the resident having an actual stage 2 pressure ulcer to the coccyx. Interventions include: Assess wound weekly, document wound measurements, wound bed appearance, odor, drainage, and surrounding tissue. Record review revealed that the facility failed to follow the plan of care for alteration in skin integrity as they did not assess the wound weekly, document wound measurements, wound bed appearance, odor, drainage, and the surrounding tissue. The Assistant Director of Nursing Services (ADNS), who is also the wound nurse, provided an undated wound assessment which he stated was completed the first week of December. This staged the pressure ulcer as a stage 2 to the sacrum. During a surveyor interview with the wound nurse on 12/13/2017 at 10:15 AM, he could not provide evidence that the wound was assessed upon admission on 11/22/2017 until an unspecified date in the first week of December. At this time, the surveyor requested to observe the wound in the presence of the wound nurse. During surveyor observation of the resident's pressure ulcer on 12/13/2017 at 10:20 AM with the wound nurse, there was a pressure ulcer on the sacrum with small amounts of slough (non-viable yellow tissue) in the wound bed, indicating a stage 3 pressure ulcer (full thickness tissue loss and slough may be present). After the above observation with the surveyor, record review of the Registered Nurse weekly wound assessment, dated 12/13/2017, documented a stage 3 pressure ulcer to the sacrum, indicating that the wound had worsened. Additional record review revealed a care plan, initiated 11/23/2017, with an intervention dated 11/30/2017 to place heel protectors (used to prevent pressure ulcers) on resident. During a surveyor observation on 12/13/2017 at 10:20 AM, resident ID #2 was observed lying in bed, with no heel protector on either heel. During an observation of the resident's heels on 12/14/2017 at 8:32 AM with two surveyors and Staff Nurse C, it was observed that the resident had a discolored, nonblanchable area to the right heel and a nonblanchable redness with a darkened area to the left heel. The resident was not wearing heel protectors and the heels were resting directly on the bed. During a surveyor interview with Staff Nurse C on 12/14/2017 at 8:35 AM, she was unaware that the resident had heel protectors in the care plan and acknowledged that there were no heel protectors in the resident's room. After an immediate jeopardy related to pressure ulcers was brought to the attention of the facility on 12/14/2017, an outside wound care consultant was brought into the facility to perform an assessment of the wounds. Review of the outside wound care consultant initial evaluation dated 12/14/2017 revealed the following assessment and measurements of the wounds: - A stage 3 pressure wound to the sacrum (wound size: 2 x 3 x 0.2 centimeters) - An unstageable Deep Tissue Injury (DTI) on the right heel (wound size: 1.1 x 11 x not measurable centimeters). - An unstageable DTI on the left heel (wound size: 1.2 x 1 x not measurable centimeters). The above documentation confirms the wound to the sacrum progressed to a stage 3 and that the resident developed a new pressure ulcer on each heel. 2. Resident ID # 85 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of a significant change assessment dated [DATE] revealed that the resident was at risk for developing pressure ulcers. The Care Area Assessment states will proceed to care plan. A Braden Scale for Predicting Pressure Ulcers score was obtained on 11/19/2017 indicating high risk for pressure ulcers. An interview was conducted with the resident on 12/13/2017 at 9:00 AM. The resident stated he/she prefers to stay in bed and does not get out of bed. Observations on 12/13/2017 at 9:00 AM, 12/14/2017 at 2:30 PM and on 12/19/2017 at 9:15 AM revealed the resident in bed with heels flat on the bed and both feet pressing up against the foot board of the bed. Further record review revealed no evidence of a plan of care addressing pressure ulcer prevention. An interview was conducted with the Administrator on 12/19/2017 at approximately 1:00 PM. She was unaware that the resident did not have a plan of care for preventing pressure ulcers and could not provide evidence that a plan of care was developed. |
2020-09-01 |