cms_VT: 80
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 |
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
80 | HELEN PORTER HEALTHCARE & REHAB | 475017 | 30 PORTER DRIVE | MIDDLEBURY | VT | 5753 | 2017-03-16 | 314 | 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 1 resident with pressure ulcers in a sample of 3 reviewed, Resident #130. 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. | 2020-09-01 |