cms_UT: 38
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 38 | HERITAGE PARK HEALTHCARE AND REHABILITATION | 465003 | 2700 WEST 5600 SOUTH | ROY | UT | 84067 | 2019-10-03 | 686 | D | 1 | 0 | CR9Z11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview and record review it was determined, for 1 of 10 sample residents, that the facility did not ensure that each resident received care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrated that they were unavoidable. In addition, a resident that developed a pressure ulcer received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. Specifically, facility staff did not document a resident's pressure ulcers upon admission. After identifying a resident's pressure ulcers treatments were not completed according to physician's orders [REDACTED]. Findings include: Resident 3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 10/2/19 at 2:42 PM, an interview and observation was conducted of resident 3. Resident 3 stated that she had wounds on her back and hips. Resident 3 stated that she had wounds Off and On at various times. Resident 3 stated that she had wounds of her feet. Resident 3's feet were observed to be wrapped with soft booties on both feet and a cushion in her wheelchair. On 10/3/19 at 12:30 PM, an observation was made of resident 3's feet with Registered Nurse (RN) 3. RN 3 was observed to remove a dressing from resident 3's right toe area. RN 3 stated that there was no bandage on the lateral foot. RN 3 stated that the wound must have been healed. RN 3 stated that the wound on resident 3's toes was probably sort of a pressure sore, I would think. Resident 3's left heel was observed to be boggy with a red area approximately 1 by 2 cm that was non-blanchable. Resident 3's feet were observed to be very dry. Resident 3 refused to have her other pressure ulcers observed. Resident 3's medical record was reviewed on 10/2/19. An admission assessment dated [DATE] at 10:22 PM revealed in the skin section, Open sore to left upper buttocks 4 x 4. Fragile skin. Bruise on abdomen. Both heels soft. Resident 3's care plan were requested from the facility on 10/17/19. The care plans that were created on 9/3/19 and revised on 10/15/19 revealed, (Resident 3) has potential/actual impairment to skin integrity r/t (related to) [MEDICAL CONDITIONS] (End Stage [MEDICAL CONDITION]) w/ (with) [MEDICAL TREATMENT],[MEDICAL CONDITION](hypertension), [MEDICAL CONDITION], incontinence, DM (diabetes mellitus), impaired mobility. Pressure injury stage 4 to left & right buttock. Pressure injury unstageable to left heel. The goal developed was, Will have no complications r/t trach, permacath site, pressure injury stage 4 to left and right buttock - pressure injury unstageable to left heel through review date. An intervention developed on 9/3/19 was, Encourage good nutrition and hydration in order to promote healthier skin and needs pressure relieving cushion to protect the skin while up in chair. Additional interventions were developed on 9/18/19, Needs pressure relieving/reducing mattress to protect the skin while in bed. Educate resident/family/caregivers of causative factors and measures to prevent skin injury. Follow facility protocols for treatment of [REDACTED]. Use lotion on dry skin. Additional interventions created on 10/7/19 with a date initiated as 9/4/19 were, Needs pressure relieving cushion to protect the skin while up in chair. Float heels while in bed. Encourage to wear Pressure relieving boots. A Skin/wound note from the Wound Nurse (WN) 9/4/19 at 1:55 PM revealed, Left buttock, pressure injury sage 4 (on admit) 2.2 cm (centimeters) L (length) x 2.0 cm W (width) x 0.7 cm D (diameter). Wound status: not healed. hyper gran (granulation): no tunneling/undermining: no. drainage: moderate serous. odor: mild. pain: 0. granulation: 50-75%. slough: 1-49%. periwound color: normal for patient. periwound texture: scar tissue. periwound moisture: maceration.Resident is new admit to facility. Resident stated that she has had this wound for over 4 years and has previously been hospitalized for [REDACTED]. Resident 2's (MONTH) 2019 Treatment Administration Record (TAR) revealed an order dated 9/5/19 for left buttock dressing to be changed on Monday, Wednesday and Friday. The first treatment was completed on 9/6/19 and there was no nurses initials on the treatment for [REDACTED]. An admission Minimum Data Set ((MDS) dated [DATE] revealed that resident 3 had 1 stage 4 unhealed pressure ulcer and was at risk for developing pressure ulcers. The MDS further revealed that resident 3 was receiving pressure ulcer care and ointments/medications other than to the feet. An admission Braden scale was completed on 10/2/19. Resident 3 had a score of 14.0 which was considered at moderate risk for skin breakdown. (Note: The first braden score was documented on 10/2/19.) A nursing note dated 9/10/19 reveled, .she had her dressings done to her buttocks area and foot, no new issues. A skin evaluation on 9/10/19 revealed, Wound to left posterior thigh dressed as ordered. No [MEDICAL CONDITION] noted. Right port per [MEDICAL TREATMENT]. Resident has redness/small wound to bridge of nose, soft pad in place this shift. Good skin turgor noted. A Skin/Wound Note dated 9/13/19 at 2:55 PM, 1. Left buttock, Pressure injury stage 4 (on admit): 5.0cmL x 7.0cmW x 0.3cmD. wound status: not healed. 2. Right buttock, pressure injury stage 4 (on admit) previously healed: 10.2cmL x 8.0cmW x 0.1cmD. Wound status: not healed.Notes: previously healed stage 4. 3. Right lateral Ankle/Foot, Arterial Ulcer (on admit): 1.7cmL x 1.5cmW x 0.1cmD. wound status: not healed.Note: area is very scarred and the skin is tight and shiny. 4. Right Medial Ankle/Foot, Arterial Ulcer (on admit): 9.0cmL x 11.0cmW x 0.1 cmD. not healed.Notes area is very scarred and the skin is tight and skiny. 5. Right Lateral 3rd toe, arterial ulcer (on admit): 1.0 cmL x 0.7cmW x 0.4cmD. Wound status: not healed.Notes: previous amputation to 4th & 5th toe. A Skin/Wound Note dated 9/16/19 at 1:38 PM revealed, Clarification of Note 9/13/19: . (Note: The note was the same as the note on 9/13/19.) An order progress note dated 9/16/19 at 4:23 PM, N.O (new order) Left buttock and R buttock: remove dressing, cleanse with NS (Normal Saline), apply skin prep to periwound, apply hydrogel to wound bed, cover with bordered gauze or bordered foam. Every day shift Mon (Monday), Wed (Wednesday), Fri (Friday). Start Date: 9/18/2019. An order progress note dated 9/17/19 at 2:26 PM, N.O. Right lateral 3rd Toe: remove dressing, cleanse with NS or soap and water, apply skin prep to periwound, apply hydrogel to wound base, cover with bordered gauze. every shift every Tue (Tuesday), Thu (Thursday), Sat (Saturday). Start Date: 9/19/19. Resident 29's (MONTH) 2019 TAR was reviewed and the first treatment documented was on 9/19/19. An order progress note dated 9/17/19 at 2:28 PM, N.O. Right Lateral Foot: remove dressing, cleanse with NS or soap and water, apply skin prep to periwound, apply hydrogel to wound bed, cover with bordered gauze or bordered foam. every day shift Tue, Thu, Sat Start Date: 9/19/19. Resident 29's (MONTH) 2019 TAR was reviewed and the first treatment documented was on 9/19/19. A Skin/Wound Note dated 9/17/19 at 2:29 PM, 1. Left Buttock, Pressure Injury Stage 4 (on admit) previously healed stage 4 pressure injury, open on admit: 4.8cmL x 7.0cmW x no measurable depth. Wound status: not healed.2. Right buttock, Pressure Injury Stage 4 (on admit) previously healed stage 4 pressure injury, not open on admit: 13.0cmL x 8.0cmW x 0.1 cmD. Wound status: not healed.3. Right Lateral Ankle/Foot, Arterial Ulcer (on admit) previously healed, not open on admit: 1.5cmL x 1.0cmW x 0.1cmD. wound status: not healed.4. Right Medial Ankle/Foot, Arterial Ulcer (on admit) previously healed, not open on admit: 0.0cmL x 0.0cmW x 0.0cmD. Wound status: Resolved. Epithelized skin is very thin. 5. Right Lateral 3rd Toe, Arterial Ulcer (on admit): 0.7cmL x 0.5cmW x 0.2cmD. wound status: not healed. Resident 2's (MONTH) 2019 Treatment Administration Record (TAR) revealed an order dated 9/16/19 for left buttock and right buttock to remove dressing, cleanse with NS, apply skin prep to periwound, apply hydrogel to wound bed, cover with bordered gauze or foam every Monday, Wednesday and Friday. The first documented treatment was on 9/18/19. A skin evaluation dated 9/17/19 revealed, Wound to left posterior thigh dressed as ordered. No [MEDICAL CONDITION] noted. right port per [MEDICAL TREATMENT]. Resident has redness/small wound to bridge of nose, soft pad in place this shift. Good skin turgor noted. A Skin evaluation dated 9/24/19 revealed, Wound to left posterior thigh dressed as ordered. No [MEDICAL CONDITION] noted. Right port per [MEDICAL TREATMENT]. Resident has redness/small wound to bridge of nose, soft pad in place this shift. Good skin turgor noted. A skin evaluation dated 10/1/19 revealed, Wound to left posterior thigh dressed as ordered. No [MEDICAL CONDITION] noted. right port per [MEDICAL TREATMENT]. Resident has redness/small wound to bridge of nose, soft pad in place this shift. Good skin turgor noted. A local wound care company's notes revealed measurements for resident 3's wounds dated 10/1/19. The following measurements were documented: (Note: All measurements were in cm.) 1. Left buttock stage 4 pressure injury. The measurements were 8.5x8.5x0.2. 2. Right lateral 3rd toe was an abrasion. The measurements were 0.6x0.5x0.1. 3. Right buttock stage 4 pressure injury. The measurements were 4.5x15x4 On 10/3/19 at 12:08 PM, an interview was conducted with Registered Nurse (RN) 2. RN 2 stated that she completed resident 3's skin assessment upon admission. RN 2 stated that resident 3 had a Big pressure ulcer on her buttock. RN 2 stated that she did not remember seeing wounds on resident 3's feet or on the right buttock. On 10/3/19 at 12:22 PM, an interview was conducted with the Director of Nursing (DON). The DON stated wound rounds were done every Tuesday. The DON stated that she needed to review resident 3's medical record regarding wound development. On 10/3/19 at approximately 1:00 PM, an interview was conducted with the Wound Nurse (WN). The WN stated that she assessed resident 3's wound the day of admission or the next day. The WN stated that resident 3 was admitted with a left ischium buttock wound, right lateral/medial and a 3rd toe wound. The WN stated that resident 3 had history of chronic wounds. The WN stated that resident had flap surgery in the past on the buttocks. The WN stated that on 9/4/19 she did not do a full body skin check and only looked at the wound on resident 3's buttock. The WN stated that she found resident 3's right foot wrapped on 9/13/19. The WN stated that she was not sure who put a wrap on resident 3's foot. The WN stated that she thought the wound looked vascular. The WN stated that she did not see resident 3's wounds on 9/24/19 with the a local wound company because resident 3 was in [MEDICAL TREATMENT]. The WN stated that resident 3 did not have shoes. The WN stated that on 10/1/19 resident 3 had booties on her feet. The WN stated that the wound Nurse Practitioner (NP) and her told the Certified Nursing Assistant's (CNA) that resident 3 needed to have booties on at all times. The WN stated that she was off for 2 weeks and did not look at resident 3's wounds for 2 weeks. The WN stated that she saw resident 3's wounds on 9/13/19, 9/17/19 and 10/1/19. The WN stated that she did not know why the wound dressing was not initialed by a nurse on 9/11/91. The WN stated that if the initials were not signed then the treatment was not completed. The WN confirmed that resident 3's wounds did not look New when she saw them for the first time on 9/13/19. The WN stated that the wounds had healing tissue which could have been developed after and admission and were healing or prior to admission. The WN stated that she completed a wound dressing change when she measured the wounds on 9/13/19 and 9/17/19 when she measured the wounds. The WN stated that she did not document what treatments were administered to resident 3's wounds. The WN stated that on 10/1/19 she discussed with CNA's the importance of the off loading boots to her feet. The WN stated that resident 3 did not have anything ordered for her dry skin to prevent further breakdown on her feet. The WN stated that she was not sure if CNAs were putting lotion on resident 3's feet. The WN stated that a communication order was put into the electronic medical record and nurses were to make sure the order was completed. The WN stated that resident 3 did not have a communication order in her medical record. On 10/3/19 at approximately 3:00 PM, an interview was conducted with the DON and the Cooperate Resource Nurse (CRN). The DON and CRN stated that resident 3 had a history of [REDACTED]. The DON stated that she contacted the nurse regarding the treatment not initialed on 9/11/19. The DON stated that the nurse tried to do the treatment but the resident refused. The DON stated that the nurse told her that she passed on the information for the next nurse. The DON stated that the nurse stated she was not sure if resident 3's treatment was completed. | 2020-09-01 |