Based on interview and record review it was determined the facility failed to implement pressure ulcer treatments for 1 of 3 sampled residents (#6) reviewed for pressure ulcers. This placed residents at risk for worsening pressure ulcers. Findings include:
Resident 6 was admitted to the facility in 8/2019 with diagnoses including diabetes, cellulitis and edema.
a. An Admission Profile dated 8/2/19 revealed Resident 6 had a pressure ulcer. The profile described an open area to the coccyx with no measurements and a non-blanchable purple area to the left buttock with no measurements, stage of wound was documented as not applicable.
On 3/18/20 at 9:42 AM Staff 10 (RNCM) confirmed the admission profile should have measurements for the wounds and stages.
b. An Admission Profile dated 8/2/19 revealed Resident 6 had a pressure ulcer. The profile described an open area to the coccyx with no measurements and a non-blanchable purple area to the left buttock, with no measurements stage of wound was documented as not applicable.
Physician orders dated 8/6/19 instructed staff to apply barrier cream to the gluteal fold and coccyx for prevention two times a day.
The TAR dated 8/2019 instructed staff to reposition Resident 6 every two hours for pressure ulcer prevention with a start date of 8/6/19. Out of 59 opportunities Resident 6 refused repositioning 26 instances. The physician was notified of the refusals.
An Initial Non-Pressure Skin Condition Assessment dated 8/7/19 revealed Resident 6's coccyx wound was first observed on 8/2/19 with measurements of two centimeters length by two centimeters width by 0.1 centimeters depth. The wound's surrounding skin was blanchable with no fluid seepage.
A 8/12/19 Significant Change Pressure Ulcer CAA revealed Resident 6 had worsening ulcers and wound development. Resident 6 had deep tissue injury to the right ischial tuberosity (bottom of pelvis bone) and moisture associated skin damage to the coccyx.
Physician's orders dated 8/12/19 instructed staff to apply antifungal cream to gluteal fold and coccyx for intertrigo (inflammatory condition of skin folds, induced or aggravated by heat, moisture, maceration, friction, and lack of air circulation) two times a day.
Nursing Note dated 8/13/19 revealed the nurse observed Resident 6's buttock area with noted decline the physician was notified and a new order was received. Resident 6 had frequent refusals of repositioning.
No documentation was found in clinical records new orders were received for Resident 6's coccyx area from 8/13/19 through 8/23/19.
On 3/18/20 at 9:42 AM Staff 10 (RNCM) stated after Resident 6's coccyx wound worsened new orders should have been implemented.
Based on interview and record review it was determined the facility failed to ensure residents consistently received restorative services after therapy was discontinued for 2 of 3 sampled residents (#s 5 and 6) reviewed for range of motion. This placed residents at risk for a decline in mobility and strength. Findings include:
1. Resident 5 was admitted to the facility in 2015 with diagnoses including lack of coordination and weakness.
A revised 6/27/19 comprehensive care plan revealed Resident 5 was started on a restorative program to prevent contractures with interventions including active range of motion three to five times a week.
A 1/2020 Documentation Survey Report revealed to provide range of motion for Resident 5 three to five times a week. Range of motion from 1/1/20 through 1/7/20 did not occur and from 1/15/20 through 1/21/20 there was one occurrence.
On 3/16/20 at 11:17 AM Staff 17 (RA) stated Resident 5 did not refuse range of motion services.
On 3/18/20 at 12:14 PM Staff 2 (RNCM) stated in 1/2020 the facility used the restorative aide as a CNA due to shortage of staff.
2. Resident 6 was admitted to the facility in 8/2019 with diagnoses including reduced mobility.
A 4/1/19 comprehensive care plan revealed Resident 6 was started on a restorative program due to general weakness with interventions including active range of motion three to five times a week.
A 1/2020 ROM Documentation Survey Report revealed the following range of motion three to five times a week. Range of motion from 6/2/19 through 6/8/19 occurred one instance, from 6/11/19 through 6/16/19 occurred one instance and one refusal and from 6/23/19 through 6/29/19 there was one occurrence.
On 3/18/20 at 9:55 AM Staff 10 (RNCM) stated the expectation for Resident 6's range of motion was three to five times a week and he did not believe it was a staffing issue.
Based on interview and record review it was determined the facility failed to provide adequate catheter care for 2 of 3 sampled residents (#s 3 and 6) reviewed for incontinent care. This placed residents at risk for unmet incontinent needs.
1. Resident 3 was admitted to the facility in 2016 with diagnoses including obstructive uropathy (urine does not flow correctly).
a. A revised 4/18/18 care plan revealed Resident 3 required a Foley catheter for urinary retention with interventions including Foley catheter care every shift and as needed, empty catheter bag every shift and as needed.
A 4/19/19 Urinary Incontinence CAA revealed Resident 3 had a Foley catheter. Resident 3's care plan would be maintained to reduce risk related to chronic Foley catheter to prevent infection, maintain skin integrity and dignity.
A 4/2019 TAR instructed staff to ensure catheter care was completed every shift and as needed with a discontinue date of 4/11/19. From 4/12/19 through 4/31/19 the TAR did not instruct staff to provide catheter care every shift.
Nursing Notes revealed documentation of Resident 3's Foley catheter was clear and was draining yellow urine or was patent for one instance for each of the following days: 4/13/19, 4/19/19, 4/21/19, 4/23/19, and 4/29/19.
No documentation was located in clinical records indicating Foley catheter care was provided every shift from 4/12/19 through 4/31/19 except when indicated above.
On 3/18/20 at 9:58 AM Staff 10 (RNCM) stated although the TAR did not have the catheter care listed he believed staff were still providing catheter care every shift. Staff 10 stated staff would usually document in nurses notes if there was a concern for a urinary tract infection.
b. A revised 4/18/18 care plan revealed Resident 3 required a Foley catheter for urinary retention with interventions including encourage fluids, monitor for retention or decreased urine output report no void during a shift or less than 200 cubic centimeters and empty catheter bag every shift and as needed.
Intake and Output records revealed:
-3/2019 14 days intake and output were not documented all three shifts.
-4/2019 18 days intake and output were not documented all three shifts.
-11/2019 eight days intake and output were not documented all three shifts.
-12/2019 11 days intake and output were not documented all three shifts.
-2/2020 10 days intake and output were not documented all three shift.
On 3/18/20 at 10:00 AM Staff 10 (RNCM) stated he would expect staff to document intake and output all three shifts.
c. A revised 4/18/18 care plan revealed Resident 3 required a Foley catheter for urinary retention with interventions including, change Foley catheter bag every month and as needed.
A 1/17/20 physician order instructed staff to change indwelling catheter as needed for blockage.
A 1/28/20 Urinary Incontinence CAA revealed Resident 3 had a chronic indwelling catheter and care plan would be developed due to indwelling catheter use.
On 3/18/20 at 9:57 AM Staff 10 (RNCM) stated the care plan should be updated to reflect Resident 3's physician ordered indwelling catheter change as needed instead of the monthly change.
2. Resident 6 admitted to the facility in 8/2018 with diagnosis including infection and inflammatory reaction due to indwelling catheter.
a. Physician orders dated 10/19/18 instructed staff to provide Foley catheter care every shift for infection prevention and to ensure catheter was safely secure every shift.
A 7/2019 TAR instructed staff to provide Foley catheter care every shift for infection prevention- and to ensure catheter was safely secure every shift with a start date of 10/19/18 and discontinue date of 8/1/19.
An 8/6/19 Nurses Note revealed Resident 6's Foley catheter was patent and draining amber urine.
No documentation was located in clinical records indicating Foley catheter care was provided every shift from 8/2/19 through 8/13/19 except when noted above.
On 3/18/20 at 9:48 AM Staff 10 (RNCM) stated he was not concerned catheter care orders were not in place from 8/2/19 through 8/13/19 as catheter care was occurring every shift.
b. Care plan dated 8/23/19 revealed Resident 6 was at risk for alteration in elimination due to Foley catheter use and to monitor for retention or decreased urine output, turbidity, odor and report no void during a shift of less than 200 cubic centimeters every shift.
Intake and Output records for the months of 7/2019 and 8/2019
-7/3/2019 through 7/30/19 eight days intake and output were not completed all three shifts.
-8/3/19 through 8/28/19 four days intake and output were not completed all three shifts.
On 3/18/20 at 10:00 AM Staff 10 (RNCM) stated he would expect staff to document intake and output all three shifts.
c. Significant Change CAA dated 8/12/19 revealed Resident 6 had a chronic indwelling Foley catheter. The CAA revealed Resident 6's care plan would be maintained secondary to alteration in elimination of Foley catheter use.
Physician orders dated 8/13/19 instructed staff to change indwelling catheter as needed for obstructive uropathy.
Care plan dated 8/23/19 revealed to Resident 6 was at risk for alteration in elimination due to Foley catheter use and to change Resident 6's Foley bag every month and PRN.
On 3/18/20 at 9:48 AM Staff 10 (RNCM) confirmed the care plan should reflect Resident 6's physician ordered Foley catheter information.
Based on interview and record review it was determined the facility failed to ensure resident records were complete and accurate for 1 of 3 sampled residents (#12) reviewed for medications. This placed residents at risk for medications. Findings include:
Resident 12 was admitted to the facility in 2/2020 with diagnoses including fracture of right leg.
a. Physician orders dated 2/4/20 instructed staff to administer one tablet of hydrocodone-acetaminophen (to relieve pain) 10-325 three times a day for pain.
The 2/2020 MAR instructed staff to administer one tablet of hydrocodone-acetaminophen 10-325 three times a day for pain. From 2/6/20 through 2/25/20 hydrocodone-acetaminophen was documented as administered three times a day.
The Narcotic Medication Log books dated 2/5/20 and 2/25/20 revealed to administer one tablet of hydrocodone/acetaminophen 10-325 three times a day for pain. The medication was documented as administered by the number as follows:
-2/6/20 four instances. One more administration than documented on the MAR.
-2/8/20 four instances. One more administration than documented on the MAR.
-2/6/20 five instances. Two more administrations than documented on the MAR.
-2/10/20 five instances. Two more administrations than documented on the MAR.
-2/11/20 five instances. Two more administrations than documented on the MAR.
-2/12/20 seven instances. Four more administrations than documented on the MAR.
-2/13/20 six instances. Three more administrations than documented on the MAR.
-2/26/20 six instances. Three more administrations than documented on the MAR.
-2/27/20 four instances. One more administration than documented on the MAR.
-2/28/20 five instances. Two more administrations than documented on the MAR.
-2/29/20 five instances. Two more administrations than documented on the MAR.
On 3/18/20 at 11:53 Staff 2 (RNCM) confirmed there were discrepancies between the Narcotic Log book and the MAR. Staff 2 stated on 2/29/20 one of the instances the staff failed to document on the MAR.
b. Physician's orders dated 2/5/20 instructed staff to administer one tablet of hydrocodone-acetaminophen (to relieve pain) 10-325 every six hours as needed for pain.
The 2/2020 MAR instructed staff to administer one tablet hydrocodone-acetaminophen 10-325 every six hours as needed for pain with a start date of 2/5/20 and a discontinue date of 2/7/20. The MAR revealed the following:
-2/5/20 one administration.
-2/6/20 three administrations.
-2/7/20 one administration.
The Narcotic Medication Log book dated 2/6/20 revealed hydrocodone-acetaminophen 10-325 administer one tablet every six hours as needed for pain. The log book revealed from 2/8/20 through 2/17/20 fifteen administrations were documented as administered.
On 3/18/20 at 11:53 Staff 2 (RNCM) confirmed there were discrepancies between the Narcotic Log book and the MARs.
c. Physician order dated 2/7/20 instructed staff to administer one tablet of hydrocodone-acetaminophen 10-325 (to reduce pain) every four hours as needed for pain.
The 2/2020 MAR instructed staff to administer one tablet hydrocodone-acetaminophen 10-325 every four hours as needed for pain. The MAR revealed the following documentation of administrations:
-2/17/20 no administrations.
-2/18/20 two administrations.
-2/19/20 one administration.
-2/20/20 one administration.
-2/21/20 four administrations.
-2/22/20 one administration.
-2/23/20 one administration.
The Narcotic Medication Log book dated 2/8/20 revealed hydrocodone/acetaminophen 10-325 to administer one tablet by mouth every four hours as needed for pain. The log revealed the following documentation of administrations:
-2/17/20 two administrations. (discrepancy of two administrations from the MAR)
-2/18/20 four administrations (discrepancy of two administration from the MAR)
-2/19/20 four administrations. (discrepancy of three administrations from the MAR)
-2/20/20 four administrations. (discrepancy of three administrations from the MAR)
-2/21/20 six administrations (discrepancy of two administrations from the MAR)
-2/22/20 four administrations. (discrepancy of three administrations from the MAR)
2/23/20 four administrations. (discrepancy of three administrations from the MAR)
On 3/18/20 at 11:53 Staff 2 (RNCM) confirmed there were discrepancies between the Narcotic Log book and the MARs.
d. Physician orders dated 2/3/20 instructed staff to administer one tablet of 5-325 hydrocodone-acetaminophen (to reduce pain) every six hours as needed for pain.
The 2/2020 MAR instructed staff to administer one tablet of 5-325 hydrocodone-acetaminophen every six hours as needed for pain. The MAR indicated the medication was administered two instances on 2/4/20.
The Narcotic Medication Log book dated 2/3/20 and 2/4/20 revealed hydrocodone-acetaminophen 5-325 administer one tablet every six hours as needed was administered on three instances on 2/4//20.
On 3/18/20 at 11:53 Staff 2 (RNCM) confirmed there were discrepancies between the Narcotic Log book and the MARs.
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OAR 411-086-0140 Nursing Services: Problem Resolution & Preventive Care
Refer to F686, F688 and F690
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OAR 311-086-0300 Clinical Records
Refer to F842
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