Challenge Scenario. Featured TAG TOPIC SCENARIO NOTES F272. Conduct initial and periodic assessments of each resident s functional capacity

Transcription

1 TAG TOPIC Conduct initial and periodic assessments of each resident s functional capacity SCENARIO In this scenario, the facility failed to make comprehensive assessments of residents needs. Could this happen at your facility? For additional details related to this scenario, see page 2 What actions would you and your staff members take to prevent this from occurring in your facility? NOTES

2 On the days of the Recertification and Extended Survey, based on observations, record review and interviews, the facility failed to make comprehensive assessments of residents needs related to 7 of 7 residents reviewed for pressure sores (Residents #14, #1, #4, #10, #3, #2 and #9). The findings included: Cross refers to F-280 as it relates to the failure of the facility to review and revise the comprehensive care plan for residents with pressure sores, Resident #14, #1, #4, #3 and #9. Cross refers to F-281 as it relates to the failure of the facility to evaluate pressure sore risk factors and implement interventions to reduce or remove the underlying risk factors, assess residents to identify the development of new pressure sores and provide appropriate care and assessments of wounds, in accordance with recognized standards of practice, to promote healing and prevent infection to residents who had pressure sores, Residents #14, #1, #4, #10, #3, #2, and #9. Cross refers to F-314 as it relates to the failure of the facility to evaluate pressure sore risk factors and implement interventions to reduce or remove the underlying risk factors, assess residents to identify the development of new pressure sores and provide appropriate care and assessments of wounds, in accordance with recognized standards of practice, to ensure the healing and prevent infection to residents with pressure sores, Residents #14, #1, #4, #10, #3, #2, and #9. Cross refers to F-490 as it relates to the failure of the facility administration to implement its resources effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. The facility s administration failed to identify and implement a plan of action to ensure residents with pressure sores received the necessary treatments and services to promote healing, prevent infection and prevent new sores from developing. Cross refers to F-520 as it relates to the failure of the facility to implement a plan of action and follow up on concerns related to pressure sore treatment. The facility admitted Resident #14 with [DIAGNOSES REDACTED]. The Admission Nursing Evaluation dated 03/24/2012 indicated under the SKIN CONDITION section that Resident #14 had two bruises on the top of head sore to the (L) (left) ear on the base of ear. (R) (right) foot on the outer apex has a quarter size black spot. Res (resident) has some sores they have cotton between bottom toes/wrap with Kerlix. Review of the Admission Minimum Data Set (MDS) dated [DATE] revealed the resident was always incontinent of bowel and bladder. The resident was coded with no pressure sores. The Quarterly MDS dated [DATE] coded the resident with 2 stage II pressure sores and no venous/arterial sores. A Nutritional Risk assessment dated [DATE] stated under the section Skin Condition/[MEDICAL CONDITION], [MEDICAL CONDITION] to (L) hand and (R) arm. Res with multiple areas of pressure ulcers.

3 Review of the closed medical record for Resident #14 on 08/01/2012 revealed Nurse s Notes from 03/24/2012 through 07/11/2012 with limited documentation related to the resident skin concerns. Review of Resident #14 s Weekly Skin Assessments completed in April, May, and June 2012 revealed documentation that a skin concern existed there were not documented assessments of the wound to include measurement, staging, drainage, and interventions. The only wound measurement available at the time of the survey were those documented by the nurse practitioners on 06/12/2012 and 06/21/2012 and documentation in the physician s progress notes related to Resident #14 s wounds. Braden Scale performed on 03/24, 03/31, 04/07, and 04/17/2012 indicated the resident was at high risk for pressure sores, 04/17/2012 was the last Braden Scale completed. The facility admitted Resident #1 with [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set (MDS) dated [DATE] revealed the resident was always incontinent of bowel and bladder. The resident was coded with no pressure sores. The Quarterly MDS dated [DATE] coded the resident with no skin concerns. A Nutritional Risk assessment dated [DATE] stated under the section Skin Condition/[MEDICAL CONDITION], blister/wounds to (L) L (lower) (E) extremity. Review of Resident #1 s medical record revealed a Progress Note dated 06/12/2012 that stated, Resident is frail and debilitated. She sustained a skin tear to her lower left leg, however, it is slow in healing and we are here as a follow-up visit. We also did review a skin body audit and found some redness on her heels and dry skin noted on her bilat. lower extremities. An area on her lower left leg measures 4 x 0.5. The wound bed is beefy. It is moist. The wound edges are somewhat macerated, however, and peeling off. Review of the Nurse s Notes from 02/22/2012 through 07/26/2012 failed to address Resident #4 wounds until after she was seen by the Nurse Practitioner on 06/12/2012. On 06/21/2012 at 10 a.m. the Nurse s Note stated, Wound Care round with NP new orders. Review of Resident #1 s Weekly Skin Assessment documented the 06/12 and 06/14/2012 wound assessments done by the nurse practitioner, there were no other skin assessments on the resident s medical record.

4 A Non-Pressure Skin Condition Record documented 04/10/2012 as the first date the area on the resident left lower extremity was observed. The measurement at that time was 1.6 cm (centimeters) x 1.8 cm. The record included an assessment on 04/17/2012 with a measurement of 1.6 cm x 1.8 cm; on 04/24/ cm x 1.2 cm; on 05/01/ cm x 1.2 cm. There was no further documentation of the wound until 06/12/2012. The Braden Scale was completed on 08/01 and 11/01/2011; on 04/20/2012. The facility admitted Resident #4 with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) dated [DATE] revealed the resident was always incontinent of bowel and bladder. The resident was coded with no pressure sores. Review of Resident #4 s medical record revealed a Wound Care Visit note dated 06/12/2012 that stated, This is a wound care visit. Nurse complains that resident has discomfort on her sacrum. On physical examination, this is an elderly female lying in her bed in no acute distress. On examination of her skin and body audit, we did find that she had bruising to bilateral forearms and lower extremities, and multiple ecchymotic areas. She did have a stage I on the right heel as well as a scab on her left heel for which both will need skin prep. She has a stage II on her sacrum that they are not aware of at this time. Review of the Nurse s Notes from 04/02/2012 through 07/28/2012 failed to address Resident #4 s wounds until after she was seen by the Nurse Practitioner on 06/12/2012. Review of Resident #4 s current medical record revealed the Weekly Skin Assessment and the Wound Evaluation Flow Sheet were not filled out, the assessment forms had the resident name and room number. There were not documented assessments of the wound to include measurement, staging, drainage and interventions. The Braden Scale was completed on 02/25, 08/12, 10/17/2011; 04/04 and 07/03/2012. The facility admitted Resident #10 with [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set (MDS) dated [DATE] revealed the resident was always incontinent of bowel and bladder. The resident was coded with no pressure sores. The Quarterly MDS dated [DATE] coded the resident with no skin concerns. A Nutritional Risk assessment dated [DATE] stated under the section Skin Condition/[MEDICAL CONDITION], blister/wounds to (L) L (lower) (E) extremity.

5 Review of Resident 10 s medical record revealed a Wound Care Visit note dated 06/14/2012 that stated, Chief Complaint: Body Audit. Resident s skin was examined today for any compromise of breakdown. Examination reveals her skin is intact except for a small area on her upper buttock sacral area. It measures approximately 0.2 to 0.3. It is barely visible. Apply Skin-Prep to the sacral wound twice a day until resolved. Review of the Nurse s Notes from 05/10/2012 through 07/24/2012 addressed Resident #10 s wound when it was identified on 05/19/2012. The skin breakdown was observed on 05/19/2012 at 2:00 PM and assessed as a stage II sacral wound that measured 3.5 x 1 centimeter. Treatment at the time included cleansing with [MEDICATION NAME] and cover with [MEDICATION NAME] every 3 days. There were no additional measurement documented until the Wound Care Visit on 06/14/2012. Review of Resident #10 s current medical record revealed the Weekly Skin Assessments were done from 05/12/2012 through 06/30/2012; the Wound Evaluation Flow Sheet was not filled out. The Braden Scale was completed on 02/25, 08/12, 10/17/2011; 04/04 and 07/03/2012. The facility admitted resident #3 with [DIAGNOSES REDACTED]. Review of the resident s medical record revealed [REDACTED]. Scar from old PU (Pressure Ulcer) noted on bottom. Redness over scrotum. Review of the Admission Minimum Data Set (MDS) dated [DATE] revealed the resident was always incontinent of bowel and bladder. The resident was scored to not have any pressure sores. A Medical Nutrition Therapy Note dated 7/13/12 at 10:00 a.m. stated, Per DON (Director of Nursing) res (resident) with 2 open areas to buttocks & sacrum. A Nutritional Risk assessment dated [DATE] stated under the section Skin Condition/[MEDICAL CONDITION], per staff 2 open areas, one to buttock & one to sacrum. Review of the Weekly Skin Assessment revealed one skin assessment dated [DATE]. The skin assessment had checked the resident s skin to be pale with [MEDICAL CONDITION] present. The body figure had a circle around the coccyx/sacral area and it was marked to have been red, as well as the right heel. There were no other weekly skin assessments. The facility failed to identify pressure sores and obtain treatment in a timely manner, the skin assessments and assessment of the Braden scale was not done on a weekly basis per the company policy to monitor the at-risk resident for skin impairment. There were no measurements of the wounds, the Braden Scale was not done on admission or weekly per the company policy. The facility admitted Resident # 2 with [DIAGNOSES REDACTED].

6 Record review on 7/31/12 at 9:30 a.m. revealed a Nurse s Note dated 4/5/12 and documented as a Late Entry that stated Stage II decubitus ulcer found to coccyx, 2 X 1.4 cm (centimeters). On 4/17/12, an assessment of the wound was documented in the Nurse s Noted stating Stage II decubitus to coccyx. Pink granulation noted. Wound margins (and) peri wound normal for skin. Progressive healing noted. Wound slightly decreased in size. (No) drainage noted. 1.4 cm X 1.2 cm. There was no additional documentation of pressure ulcer assessments by the nursing staff. Review of the Weekly Skin Assessments for the resident revealed skin assessments were done on 5/4/12, 5/15/12, 6/5/12, 6/8/12, and 6/22/12. There were no skin assessments for the month of July. Review of the Nurse s Notes also revealed a note dated 6/13/12 at 2:45 PM that stated LE (late entry) 6/12/12. Complete body audit completed by (nurse practitioners). New orders received. During an interview on 8/1/12 at 7:48 a.m., the Director of Nursing confirmed that Weekly Skin Assessments were missing for two weeks in May, one week in June and that there were none for the month of July. She also confirmed that the wound had been assessed and measured only twice; upon discovery and two weeks later on 4/17/12. In addition, she verified that the information in the medical record was not consistent regarding the date the pressure ulcer was healed. She further confirmed that the wound should have been assessed weekly and documented. The facility admitted Resident #9 with [DIAGNOSES REDACTED]. Record review at approximately 2:10 PM on 7/31/12 revealed a progress note by NP #1 dated 7/3/12 that stated, Upon further examination or (sic) his feet, we did notice a blood filled blister on the heel of his right foot and was diagnosed as a pressure ulcer. The note further directed that physical therapy be provided to the left foot only until the wound was resolved. Further review revealed the MD assessed Resident #9 on 7/12/12 and stated the resident developed the pressure ulcer performing his physical therapy exercises. The wound was described as about the size of a quarter and soft with no signs of infection. The MD recommended to avoid pressure and monitor for other signs of inflammation. On 7/18/12 the MD again assessed the wound at the request of the resident. He described the wound as silver-dollar sized area of the blister that is broken. The central part is still dark, it is ischemic, and possibly will open up but the skin is tight over that at this time. The physician further stated, The patient has diabetes and needs to be watched closely.

7 NP #2 evaluated the resident on 7/19/12 and stated that the resident had reported tenderness on his foot and that the resident had continued to do foot slides in therapy. NP #2 described the wound as an unstageable deep tissue injury. Measurements were given as 4 X 5 cm and she stated there was a slight odor on his foot. NP #2 indicated that she spoke to NP #1 who reported she had visualized the blister and had did talk to therapy regarding how he got it and had advised not to do any further foot slides in therapy. Recommendations at that time were for a heel guard and boot to the right lower extremity at all times. Review of the Physician s Telephone Orders revealed an order dated 7/19/12 for heel floating boot to RLE (Right Lower Extremity) at all times. During observation of the wound care to his heel on 7/31/12 at 2:35 p.m., Resident #9 stated that he did not wear any kind of boot during the day; only at night to keep him from rubbing his heel in the bed. On 7/23/12 NP #1 evaluated the wound and recommended a change in treatment. Review of the Nursing Home Initial History & Physical showed the resident had chronic stasis changes in the lower extremities. Nursing recommendation was to watch for resolution of abrasions he had sustained prior to admission and for further skin breakdown. Continued review of the record revealed there were no skin assessments since admission. On 8/1/12 at 9:10 a.m., record review revealed a Braden Scale for Predicting Pressure Sore Risk assessment was completed on admission with a score of 19, at risk being a score of Review of the Nurse s notes revealed Resident #9 had voiced heel pain on 7/11/12 and received pain medication but there was no documentation that the resident s heel was assessed. There was no documentation of a pressure ulcer until 7/18/12 when the CNA reported drainage from the site and the wound was assessed by a Registered Nurse at that time. On 7/26/12 the nurse documented there was no drainage noted from the wound but no further assessment was documented in the Nurse s Notes. A wound Evaluation Flow Sheet was initiated 7/30/12 with wound measurements of 4.2 X 5.2 cm and described the exudate but was otherwise incomplete. Review of the laboratory studies done on 7/20/12 revealed the resident s [MEDICATION NAME] and [MEDICATION NAME] were both low. A note on the report signed by the NP stated Unstageable pressure area R(ight) heel. Review of the resident s care plan revealed a care plan for current skin problems and listed a surgical wound and bruises. There was no care plan implemented for potential for skin problems on admission or for actual pressure ulcer.

8 At 10:22 a.m. on 8/1/12, the Director of Nursing confirmed there was no care plan for either the pressure ulcer or the potential for skin breakdown. She further confirmed there were no skin assessments completed. The DON also verified that there were no ongoing assessments of the wound by the nursing staff and that the documentation related to the wound was incomplete. She further confirmed that the resident was not wearing a heel floating boot to the right heel at all times as had been ordered. In addition, during an interview on 8/1/12 with NP #1 revealed that she had given a telephone order the previous week to send Resident #9 to the wound clinic but did not recall which nurse she gave the order to. She further stated that she called the facility on 7/31/12 to ascertain when the resident was going back for a follow-up visit and learned that the resident had not been sent to the wound clinic. Upon arrival at the facility on 7/31/12 she gave another order for Resident #9 to be sent to the wound clinic. Additionally, NP #1 stated there was a Wound Tracking Worksheet that the facility was supposed to be utilizing but confirmed that she had not seen any of the worksheets to review. Review of the U.S. Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research, treatment of [REDACTED]. In addition, it advises, Reassess pressure ulcers at least weekly. If the condition of the patient or of the wound deteriorates, reevaluate the treatment plan as soon as any evidence of deterioration is noted. On 08/01/2012 at 2:15 p.m. the Administrator and the Director of Nurses were notified that Substandard Quality of Care and/or Immediate Jeopardy was identified at F-272, F-280, F-281, F-314, F-490 and F-520 at a scope and severity of L. The Substandard Quality of Care and/or Immediate Jeopardy existed in the facility on 06/28/2012 when the facility failed to follow through with skin assessments started on 6/12/12 and repeated on 6/21/12, related to validated concerns of wounds not identified and assessed, wound care not documented and/or provided and failing to revise or review care plans of at risk residents. The Substandard Quality of Care and/or Immediate Jeopardy (IJ) identified at F-272, F-280, F-281, F-314, F-490 and F-520 at a scope and severity of L remained ongoing at the time the survey was completed on 08/02/2012.