cms_VT: 78
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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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 78 | HELEN PORTER HEALTHCARE & REHAB | 475017 | 30 PORTER DRIVE | MIDDLEBURY | VT | 5753 | 2017-03-16 | 281 | E | 0 | 1 | LMI011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews the facility failed to provide evidence that wounds were assessed and documented according to accepted professional standards for 2 residents with pressure ulcers in a sample of 3 reviewed, Resident #130 and #202. Findings include: 1). Per record review Resident#130 has a Deep Tissue Injury (DTI) to his/her Left (L) heel. The resident was admitted to the facility on [DATE] with a documented DTI on his/her Left Heel. In the Electronic Medical Record (EMR) there are Skin notes in the Nursing documentation that on 10/25/2016 Resident #130 is noted to have scab(s) dark scab intact to left heel. Approx (approximately) the size of a nickel. Receives turning/repositioning program. float heels-pillow scab(s) intact on left heel otherwise skin intact. Skin intact to the left heel pressure ulcer. A note dated 11/2/16 states scab(s) DTI continues to L Heel. scab(s) knee Rt.(right)( heel, 2 cm (centimeter) diameter. A note dated 11/10/16 states scab(s) intact to L heel (DTI). float heels-pillow. Skin intact, 3-4 cm dark circular spot, dry. Elevated heels.scab(s) (DTI) intact to left heel; heels elevated; skin prep applied; continue to monitor. Throughout the record, notes constantly have inconsistent content and wound descriptions. In an interview on 3/14/17 at 3:05 PM the Director of Nursing Services (DNS) stated that it is expected that when a wound is present it is evaluated/assessed daily and the documentation of that assessment will contain stage and wound measurements. In a review of the facility policy for Pressure Ulcer Management a clear description of wound evaluation includes wound measurement and staging of a wound and includes an attachment with illustration of various Pressure Ulcer stages. The DNS confirmed that each unit has the policy on the unit. In an interview on 3/15/17 at 2:25 PM a Registered Nurse (RN) stated that the measurement of wounds is done by either an Licensed Practical Nurse (LPN) or an RN and that staging of wounds, done only by an RN, is done about every two months on a chronic wound. (See also F314) 2). Per record review Resident #202 was admitted on [DATE] following a right [MEDICAL CONDITION] repair. The skin assessment from 3/1/17 at 23:26 (11:26 PM) noted that the Resident had an intact surgical incision on right hip, swelling to the right lower extremity just above the knee, and a small reddened area inside right buttocks that was not open and to which moisture barrier was applied. Upon further review of skin assessments for Resident #202, on 3/11/17 Resident #202 developed a blister on his/her right heel, with light serous (clear fluid) drainage; on 3/12/17 the blister on the right heel had light serous drainage; on 3/13/17 the blister on right the heel had light serosanguinous (fluid that is blood tinged) drainage, and at 21:59 PM the blister was open on the right heel with no drainage present. Per observation on 3/14/17 at 11:44 AM, the Resident's right heel had a beefy, red opened area, measuring 3 centimeters x 2.5 centimeters. Prior to the surveyor's observation on 3/14/17, there was no evidence of any measurements and/or staging of the wound in the medical record. Per interview on 3/15/17 at 1:35 PM with the DNS, s/he stated that s/he would classify a blister as a Stage 2 pressure ulcer and would expect a blister to be staged, measured and documented by the Registered Nurse who performed the skin assessment. Per interview on 3/15/17 at 2:44 PM with the Unit Manager s/he also confirmed that a blister would be a Stage 2 pressure ulcer and would expect the Registered Nurse performing the skin assessment to stage and measure the wound appropriately. Per review of the facility Skin Care Guidelines it states, Refer to the following protocols for alteration in tissue integrity related: prevention/treatment guidelines, pressure ulcers, friction and shear, incontinence/moisture, yeast/candidiasis, skin tears, non pressure skin injury (bruising). Prevention/Treatment Guidelines-Step 1: Recognition-Examine the patient's skin thoroughly to identify existing pressure ulcers. Step 2: Determine if the patient is at risk for pressure ulcers and manage pressure. Step 3: Characterize the pressure ulcer (staging) and assess the patient's overall physical and psychological health. (See also F309) *In a position statement article by the W[NAME]N Society (Wound, Ostomy, and Continence Nurses) it clearly states: Accurate and thorough documentation is essential for effective prevention and management of pressure ulcers. Good documentation must be comprehensive, consistent, concise, chronological, continuing and reasonably complete. (Ayello et al., 2009). According to Dahlstrom et al. (2011), initiation of appropriate treatment of [REDACTED].e., location, stage, and size), and ongoing measurements and descriptions of the wound are necessary to monitor the progression of the wound and the effectiveness of interventions. However, based on a retrospective chart review, Dahlstrom et al. found documentation of the characteristics of pressure ulcers was frequently missing key descriptors, such as the stage, location and size; and therefore, was not meeting quality guidelines. *Source: Wound, Ostomy, and Continence Nurses Society. (2017) W[NAME]N position paper: Avoidable vs. unavoidable pressure ulcers (injuries). Mt[NAME]NJ: Author. Copyright (YEAR) by the Wound, Ostomy, and Continence Nurses Society (TM) (W[NAME]N). Date of Publication: (MONTH) 22,2017. | 2020-09-01 |