cms_WY: 7
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 |
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7 | GRANITE REHABILITATION AND WELLNESS | 535013 | 3128 BOXELDER DRIVE | CHEYENNE | WY | 82001 | 2019-04-11 | 686 | D | 1 | 1 | TYBQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, medical record review and staff interview, the facility failed to ensure 1 of 12 sample residents with pressure ulcers (#8) consistently received treatments in accordance with physician orders. The findings were: Review of the 1/17/19 significant change MDS assessment showed resident #8 had severe cognitive impairment, required extensive or total assistance with all ADLs and was at risk for developing pressure ulcers. Further review showed the resident was always incontinent of bladder and bowel and did not have pressure ulcers. Review of the care plan interventions, revised 8/29/18, showed staff were directed to check the resident frequently, assist with toileting as needed, and complete weekly and as needed skin assessments. The following concerns were identified: a. Observation on 4/7/19 from 4:45 PM to 8:40 PM (almost 4 hours) showed the resident sat in his/her wheelchair in the dining/common area. During the continuous observation staff did not offer or provide toileting assistance, check for incontinence, or provide incontinence care. Observation at 8:40 PM showed CNA #6 and CNA #8 transferred the resident to bed, removed his/her urine- and feces-soiled disposable brief, then provided incontinence care. At that time, an uncovered pressure ulcer on the resident's coccyx area was observed. This area was moist, pink and approximately dime-sized. b. Continuous observation on 4/8/19 from 8:50 AM to 2:30 PM (5 hours and 50 minutes) showed the resident sat in his/her wheelchair in the dining/common area. During the observation staff did not offer or provide toileting assistance, check for incontinence, or provide incontinence care until the resident was transferred to bed at 2:30 PM. At that time CNA #2 and CNA #9 removed the urine-soaked disposable brief and exposed the uncovered pressure ulcer on the resident's coccyx area. c. Review of the wound care treatments showed the current treatment was to cleanse the area with wound cleanser, pat dry, apply skin prep, cover with [MEDICATION NAME] and change every 3 days and as needed. Further review showed this treatment was ordered on [DATE] for the area assessed as an unstageable pressure injury. d. Review of the (MONTH) 2019 to (MONTH) 2019 nursing daily progress notes showed the area remained unchanged. e. Interview on 4/9/18 at 11:21 AM with the wound care nurse revealed the pressure ulcer should have been covered with the [MEDICATION NAME] dressing. She also stated the facility had a system for reporting and documenting changes in wounds and pressure ulcers, but did not have a system for ensuring the nurses provided the treatments consistently as ordered. | 2020-09-01 |