F309H · Actual harm, pattern This citation pertains to Intake #: MI 968
Based on observations, interviews, and records review, the facility failed to provide adequate pain control for 4 of 5 residents (#100, 101, 102 and 103) resulting in escalating pain, immobility, [MEDICAL CONDITION], and increasing anxiety, depression, loss of self esteem, and feelings of dehumanization.
Findings include:
The State of Michigan's Practice Guidelines for Pain Management require that facilities address four separate areas in their pain management programs. There are a total of 19 items under these four topics. The topic of Pain Assessment and Problem Recognition requires: 1) assessment for pain within 24 hours of admission; 2) documentation of identified triggers for pain on the MDS (Minimum Data Set); 3) consideration of significant risk factors that reflect pain or the risk for having pain; 4) documentation of characteristics of the pain, including onset, location, intensity, etc; 5) documentation of alternate methods of communication for non-verbal residents; 6) Notification of a physician of the presence of symptoms that may represent pain. The second topic, [DIAGNOSES REDACTED]. have changed the management of the pain. The third area to be addressed, Care Plan-Treatment & Management of Pain, lists six tasks: 10) documentation of interventions that were initiated at the time of recognition of the resident's pain; 11) documentation of a goal for the resident's pain management; 12) cause-specific or symptomatic interventions targeted to the individual resident's painful conditions, risks for pain, and the resident's ability to cooperate with a pain management program; 13) documentation of the participation of a physician and/or a physician extender in identifying or authorizing symptomatic or cause specific interventions/treatments; 14) documentation of consistent implementation of a care plan for pain management that included appropriate symptomatic and/or cause-specific interventions; and 15) documentation of the rationale for not implementing or continuing potentially appropriate interventions. The final section, Pain: Monitoring has three tasks: 16) evaluation of the status of the resident's pain and effectiveness of implemented interventions; 17) consideration of alternative interventions; 18) documentation of the monitoring for significant effects, side effects, and complications of the pain interventions; and 19) documentation of actions taken to monitor and address adverse drug reactions related to pain management-or documentation of the reason this was not feasible or relevant.
Four of the four records reviewed contained an initial assessment of the Residents' pain. However, the assessments did not consistently identify and document the onset, location, intensity of the pain or note the triggers and alleviating factors for the pain. The assessments did not identify risk factors associated with the pain. Those residents who could not verbalize their pain did not receive prn (as needed) pain medication. The physicians for two of the four residents with pain were notified that these residents were in pain. There was no evidence that the physicians for the other two residents were notified of the residents' pain.
None of the four residents with pain had the type of pain identified (muscle, soft tissue, bone, nerve, etc). Two of the four had a [DIAGNOSES REDACTED].
Four of the four plans of care for management of pain were missing a statement of the Resident's goal for pain management. None of the four plans of care contained individualized, resident-specific interventions to reduce pain.
All four of the residents with pain had orders for pain assessment daily. The daily pain assessment consisted of recording a number on the pain scale (1-10) that the resident associated with their pain at the time of the assessment. There was no documentation for any of the four residents reflecting their type of pain, the duration, characteristics, or interference with activities of daily living (ADLs).
There was no evidence of consistent attempts to evaluate the efficacy of medications ordered for pain relief.
There was no evidence of consistent attempts to intervene when pain medications were ineffective for controlling the resident's pain.
Resident # 100:
According to the admission record, Resident #100 was an [AGE] year old man, who was admitted to the facility on [DATE] for physical rehabilitation following surgery. Resident #100 was diagnosed with [REDACTED].
According to the admission MDS, dated [DATE], Resident #100 required extensive assistance from one staff member to complete his ADLs including moving about in bed, transferring into and out of bed, moving about the facility in a wheelchair, bathing, dressing, toileting, and eating. The pain assessment portion of the MDS documented that Resident #100 had moderate pain on a daily basis. This pain assessment did not include pain triggers, risk factors, Resident #100's method of communicating pain, characteristics of his pain, Resident #100's goal for pain control, individualized interventions, documentation of effectiveness of pain medication given, causes of pain or cause-specific interventions.
Resident # 100's plan of care to prevent pain, dated 10/14/10, identified his left ankle as his painful site. The interventions listed were: 1) Assess effects of pain on patient such as accompanying symptoms, sleep, appetite, physical activity, relationships with others, emotions, ability to concentrate, etc. 2) Monitor for and report any nonverbal expressions of pain, such as moaning, striking out, grimacing, crying, thrashing, change in breathing, etc. 3) Monitor for and report GI distress (gastrointestinal symptoms) secondary to [MEDICATION NAME] (pain medication) such as nausea, vomiting, diarrhea, constipation 4) Notify physician and patient's significant other of any significant changes 5) Give PRN meds for breakthrough as per MD orders and note the effectiveness 6) Evaluate pain characteristics: intensity, location, precipitating/relieving factors 7) Evaluate for and report pain signs/symptoms i.e. exact location, character, severity, contributing factors/history breath sounds, guarding, skin color/temperature, non-verbal signs of discomfort 8) Notify physician if pain frequency/intensity is worsening or if current [MEDICATION NAME] regimen has become ineffective; PT/OT evaluation and treatment per orders.
According to Resident # 100's daily pain score for the month of November 2010, he had pain on 11/9 at level 1, 11/12 at level 3, 11/15 at level 3, and 11/18 at level 2.
The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] four doses on 11/26, four doses on 11/27, three doses on 11/28, three doses on 11/29, and four doses on 11/31.
Resident #100's physical therapy progress notes for the week ending 10/22/10 noted that he had frequent pain during therapy sessions, especially when standing. The therapist documented that diathermy treatments (high frequency electromagnetic currents) were given to Resident #100 to address his pain. The nurses' notes for the week ending 10/22/10, contained three notations, dated 10/17, 10/19, and 10/22. The notation for Sunday, 10/17/10 documented that Resident #100 was medicated for pain in his left foot at 9:30 AM. The 10/19/10 notation stated that Resident #100 had no complaints of pain. On Friday, 10/22/10, made no mention of pain.
The Physical Therapy note, dated 10/29/10, documented that Resident #100 complained of right hip pain that was so severe he could bear weight for only 30 seconds at a time with maximal support from a therapist. The Nurses' Notes for the week ending 10/29/10 had five entries. The entry for 10/25/10 noted that Resident #100 complained of pain and was given pain medication as prescribed. On 10/26/10, a nurse wrote that Resident #100 was medicated for a complaint of pain in his right leg that he rated as 7 out of total of 10 points. The 10/27/10 and 10/28/10 notes documented that Resident #100 had no complaints of pain. On 10/29/10, a nurse wrote that Resident #100 was medicated one time for "generalized pain".
For the week ending on 11/5/10, the physical therapist wrote that Resident #100 was complaining of pain in his right hip with an intensity score of 6/10. Diathermy was documented as "continuing". His progress in therapy was described as "minimal". A 10/31/10 Nurses' Note stated that Resident #100 was medicated once for pain with effective results. On 11/1/10, a Nurses' Note documented that resident #100 was medicated once for pain. On 11/3/10, a Nurses' Note documented that Resident #100 complained of knee pain and was medicated for pain. Nurses' Notes for 11/4/10 and 11/5/10 stated Resident #100 had no complaints of pain.
The Physical Therapy progress note for the week ending 11/12/10 stated that Resident #100 "did not show any consistent progress". The therapist noted that discharge plans were being made for Resident #100, although he made minimal progress with physical therapy. Nurses' Notes for 11/7/10 stated that Resident #100 received prn pain medication with relief. On 11/12/10, the Nurses' Note documented that Resident #100's pain medication was changed from prn to a schedule of every 8 hours, according to his family's request.
A Nurses' Note, dated 11/15/10, documented that Resident #100 told the nurse that he had no pain during therapy on days that he was given his pain medication prior to therapy. This had occurred since Resident #100's pain medication was put on a regular every 8 hour schedule at 6:00 AM. 2:00 PM, and 10:00 PM. The Physical Therapy note, dated 11/18/10, stated that Resident #100 was being discharged from physical therapy because he was "not making any progress." Nurses' Notes after 11/15/10 contained no references to pain.
The facility's failure to manage Resident #100's pain limited his participation and, therefore, the benefit he received from physical therapy treatments. Lack of communication between nursing and therapy lead to Resident #100 being discharged from therapy just as his pain was beginning to be controlled.
Resident #100 was discharged to his daughter's home with a referral for Home Care Services on 12/3/10.
Resident #101:
According to the admission record, Resident #101 was a [AGE] year old woman, who was transferred to the facility from another long term care facility on 10/18/10. Resident #101's [DIAGNOSES REDACTED]. She also had stage 2 pressure sores on her right hip and left heel. During this admission to the facility, Resident #101 also developed a pressure sore on her left buttock. Additionally, Resident #101 had muscle contractures ( abnormal shortening of the muscle tissue from lack of use making stretching of the joints very painful) of her hips, knees, and ankles.
Resident #101's initial pain assessment included risk factors for pain, method of communicating pain, and pain characteristics. There was no resident-identified goal for controlling her pain. The cause of Resident #101's pain was listed as [MEDICAL CONDITION] (originating from the nerves). There was no mention of pressure sores or contractures as possible sources of pain.
Resident #101's daily pain audits documented that she had no pain except for four days: 11/26/10, with a score of 2 on a scale of 1-10; and 11/27/10, 11/28/10, and 11/29/10 with a score of 3 for each day. There were no other dimensions of pain documented with these scores. there were no other periodic pain assessments documented.
The plan of care created on 10/28/10 to address Resident #101's pain listed these interventions: 1) Assess effects of pain on patient such as accompanying symptoms, sleep, appetite, physical activity, relationships with others, emotions, ability to concentrate, etc. 2) Monitor for and report any nonverbal expressions of pain, such as moaning, striking out, grimacing, crying, thrashing, change in breathing, etc. 3) Monitor for and report GI (gastrointestinal) distress secondary to [MEDICATION NAME] (pain control methods) such as nausea, constipation, or diarrhea; 4) Moiety physician and patient's significant other of any significant changes; 5) Administer pain medications as per MD orders and note the effectiveness; 6) Evaluate pain characteristics, intensity, location, precipitating/relieving factors; 7) Evaluate for and report pain signs/symptoms i.e. exact location, character, severity, contributing factors/history, breath sounds, guarding, skin color/temperature, non-verbal signs of discomfort; 8) encourage rest after medication to facilitate relief; 9) Encourage/assist to reposition frequently to a position of comfort; 10) Notify physician if pain frequency/intensity is worsening or if current [MEDICATION NAME] regimen has become ineffective. The surveyor observed staff members as the implemented intervention number 8 and number 9 during this investigation. There was no evidence that any of the other interventions for the 10/28/10 plan of care were implemented.
At admission, Resident #101 was ordered [MEDICATION NAME] (an oral narcotic pain medication) to be given one tablet every four hours as needed (Resident #101 would be medicated when she specifically requested this medication). This order was changed on 10/25/10 to two tablets every six hours around the clock (The medication was scheduled to be given at 10:00 AM, 2:00 PM, and 6:00 PM, without a specific request from Resident #101).
According to the narcotic reconciliation sheets, Resident #101 received fewer doses of [MEDICATION NAME] than ordered by the physician on 10/25/10, 10/26/10, when she reported a pain score of 2; on 10/27/10, when she reported a pain score of 3; on 10/20/10, with a reported pain score of 3; as well as on 10/30/10 through 11/3/10 and 11/9/10, 11/10/10, and 11/17/10.
Entries into Nurses' Notes for 10/22/10, 10/28/10, 10/30/10, and 10/31/10 stated that Resident #101 refused to be moved or turned on those days. There was no documentation of Resident #101's pain level on those specific days. On 11/17/10, an entry into Nurses' Notes recorded that Resident #101 complained of pain at a level of 8 out of 10. This note documented that Resident #101 was given her regularly scheduled [MEDICATION NAME] for pain. On 11/16/10, a Nurses' Note stated that Resident #101 complained of pain when nurse aides turned her for the nurse to re-dress the pressure sores on her right hip, right heel, and left buttocks.
According to Nurses' Notes, Resident #101 received an order for [REDACTED]. On 11/23/10, Resident #101 again refused to be turned, saying she was most comfortable lying on her left side.
The surveyor observed Resident #101's wounds on 12/8/10 at 1:35 PM as staff nurse #9 and nurse aide (CNA) #8 changed her dressings. CNA # pulled Resident #101 further onto her right side, so nurse #9 could change dressings on Resident #101's left knee (inner aspect), left buttock (at the midline), and left heel. Resident #101 moaned and grimaced as she was turned. The surveyor noted that Resident #101's left knee wound was comprised of a cluster of dried blisters. Her left buttock wound, a stage 2 pressure sore, involved several layers of pink and red, raw skin. When her left leg was raised to provide access to her heel, Resident #101 screamed in pain. Her heel appeared as a black callus with a raw, pink center.
At the completion of Resident #101's dressing changes, an interview was held with nurse #9, who changed Resident #101's dressings. Nurse #9 said Resident #101 moans and screams during all of her dressing changes. The surveyor asked Nurse #9 whether Resident #101 had received pain medication, as specified by the plan of care, prior to beginning the dressing procedures. Nurse #9 reviewed Resident #101's pain medication as: [MEDICATION NAME] to be changed every third day, [MEDICATION NAME] every six hours around the clock, and tylenol for headache. Nurse #9 said she checked Resident #101 and assured herself that the [MEDICATION NAME] was in place. She said she had administered Resident #101's 10:00 AM [MEDICATION NAME]. She pointed out that it was now midway between the morning dose and the evening dose, to be administered at 4:00 PM. Nurse #9 said she did not think the over-the-counter tylenol would help very much with the pain Resident #101 experienced during dressing changes. Nurse #9 said she would like to see ana order for Resident #101 to have another medication for breakthrough pain that could be administered before dressing changes and when repositioning Resident #101, but there was no such order.
Resident #102:
According to the admission record, Resident #102 was an [AGE] year old woman, who was admitted to the facility on [DATE] following hospitalization for hypertension (high blood pressure), diabetes mellitus (inability of the body to process carbohydrates effectively), diabetic [MEDICAL CONDITION] (a complication of diabetes that causes inability to feel physical sensations on the feet and may create painful sensations due to degeneration of the peripheral nerves).
According to the MDS, Resident #102 was independent with moving about the bed, getting in and out of bed, walking about the facility, toileting, bathing, and dressing. She needed assistance at meals to open cartons and covered liquids.
According to the initial pain assessment, Resident #102 would receive regularly scheduled medications to address her pain. There were no pain triggers identified. No risk factors were identified. The was no documentation of Resident #102's method of communicating pain or of her goal for pain control. There was no evidence of identified individualized interventions. There was no evidence of periodic reassessments and no documentation of the effectiveness of the ordered pain medications. There was no documentation of one or more identified causes for Resident #102's pain.
Resident #102's medication orders to address pain were: [MEDICATION NAME] (narcotic preparation), [MEDICATION NAME] (non-narcotic preparation), and [MEDICATION NAME] (oral narcotic) to be given as needed to a maximum of 4 doses daily.
A plan of care, written for Resident #102 on 9/27/10, listed these interventions: 1) adjust times of ADL and treatment activities so that (they) occur after [MEDICATION NAME] benefits have been achieved (after her pain medication has taken effect and before it has worn off) 2) Assess effects of pain on patient such as accompanying symptoms, sleep, appetite, physical activity, relationships with others, emotions, ability to concentrate, etc. 3) Monitor for and report GI distress secondary to [MEDICATION NAME] such as nausea, constipation, diarrhea 4) Administer pain medication as per MD orders and note the effectiveness; 5) Give prn meds for breakthrough as per MD orders and note the effectiveness; 6) Evaluate pain characteristics: intensity, location, precipitating/relieving factors; 7) Encourage rest after medication to facilitate relief; 8) Encourage/Assist to reposition frequently to position of comfort; 9) Notify physician if pain frequency/intensity is worsening or if current [MEDICATION NAME] regimen has become ineffective; 10) PT/OT evaluation and treatment per orders.
Documentation of daily pain scores were all negative with these exceptions: 9/25/10, level 5; 9/28/10, level 5; 9/29/10, level 5; 9/30/10, level 6; 10/4/10, level 5; 10/5/10, level 2; 10/8/10, level 3; 10/9/10, level 2; 10/10/10, level 2; 10/11/10, level 2; 10/13/10, level 3; 10/17/10, level 6; 10/18/10, level 2; 10/23/10, level 3; 10/25/10, level 5; 10/31/10, level 2. Nurses' notes for the same time period read: 9/21/10, "terrible pain in feet"; 9/22/10, pain in feet continues; 9/23/10, "requested pain med before due- slept after given"; 9/28/10, complaining of chronic pain in feet-requesting medication for foot pain; 10/9/10, complaining of pain to feet at level 7-scheduled pain med given; 10/11/10, Says feet always hurt; 10/15/10, complaining of bilateral foot pain. There was no evidence that Resident #102's unrelieved pain was reported to her physician.
According to the narcotic record, Resident # 102 received [MEDICATION NAME] as follows: 9/24/10, 2 doses; 9/25/10, 4 doses; 9/26/10 4 doses; 9/27/10, 5 doses; 9/28/10, 4 doses; 9/29/10, 3 doses; 9/30/10, 4 doses; 10/1/10, 4 doses; 10/2/10, 3 doses; 10/3/10, 4 doses; 10/4/10, 3 doses; 10/5/10, 3 doses; 10/6/10, 4 doses; 10/7/10, 4 doses; 10/8/10 4 doses; 10/9/10, 4 doses; 10/10/10, 4 doses; 10/11/10, 3 doses; 10/12/10, 4 doses; 10/13/10, 4 doses; 10/14/10, 1 dose; 10/15/10, 4 doses; 10/16/10, 2 doses; 10/17/10, 4 doses; 10/18/10, 4 doses; 10/19/10, 4 doses; 10/20/10, 3 doses, and 10/21/10, 3 doses.
Of the 28 days Resident #102's received medication for breakthrough pain, only 15 were identified on the Treatment Administration Record (TAR) as days when Resident #102 had pain, indicating that nurses identified the presence of pain more frequently than they documented it.
Resident #103:
According to the admission record, Resident #103 was a [AGE] year old woman, who was admitted to the facility on [DATE] following hospitalization for fractured pelvis, sustained when she fell at home, and [MEDICAL CONDITION]. [MEDICAL CONDITION] (a condition marked by airway resistance with difficulty breathing out) is among Resident #103's diagnoses.
According to Resident #103's plan of care, she is very short of breath and requires assistance from staff members to move about in bed, to get into and out of bed, to move about the facility, to toilet, bathe, dress, and eat.
Resident #103's admission MDS noted that she experienced pain. There were no other details regarding pain present in the MDS.
The facility's pain assessment captured pain triggers, characteristics, and risk factors. There was no documentation of the manner in which Resident #103 communicates her pain or her goal for controlling her pain. There were no assessments following the initial assessment. The cause of Resident # 103's pain was identified as right hip and back pain related to her fractured pelvis. The intensity level was documented as 5/10. The pain was characterized as "aching" in Resident #103's right thigh. Alleviating conditions were listed as medication and repositioning; aggravating conditions were listed as walking and bending.
Resident #103's care plan for pain management, dated 11/9/10, listed these interventions: 1) Adjust times of ADL and treatment activities so that (they) occur after [MEDICATION NAME] benefits have been achieved; 2) Assess effects of pain on patient such as accompanying symptoms, sleep, appetite, physical activity, relationships with others, emotions, ability to concentrate, etc. 3) Monitor for and report any nonverbal expressions of pain such as moaning, striking out, grimacing, crying, thrashing, change in breathing, etc. 4) Monitor for and report GI distress secondary to [MEDICATION NAME] such as nausea, constipation, diarrhea; 5) Notify physician and patient's significant other of any significant changes; 6) Administer pain medication as per MD orders and note the effectiveness; 7) Give prn meds for breakthrough as per MD orders and note there effectiveness; 8) Evaluate pain characteristics: intensity, location, precipitating/relieving factors; 9) Evaluate for and report pain signs/symptoms i.e. exact location, character, severity, contributing factors/history, breath sounds, guarding, skin color/temperature; non-verbal signs of discomfort; 10) Encourage rest after medication to facilitate relief; 11) Encourage/Assist to reposition frequently to position of comfort; 12) Provide education to family/patient; 13) Notify physician if pain frequency/intensity is worsening or if current [MEDICATION NAME] regimen has become ineffective; and 14) PT/OT evaluation and treatment per orders.
Resident #103's daily pain scores were recorded for the dates of 11/27/10 through 11/30/10. All four scores were recorded as zero.
The admission Nurses' Note, dated 11/9/10, recorded that Resident #103 complained of pain at a level of 5 on a scale of 1-10 and the physician was notified of this complaint. None of the other Nurses' Notes mention pain.
Resident #103 had these orders for pain control: [MEDICATION NAME] (a non-narcotic [MEDICATION NAME] pain reliever that is absorbed through the skin) and tylenol (a mild, oral non-prescription pain medication) every four hours as needed.
During an interview on 12/9/10 at 1:24 in her room at the facility, Resident #103 was sitting in her wheelchair with her head hanging down. She was wearing nasal oxygen connected to a tank on the back of her wheelchair. Resident #103 told the surveyor that she was not doing very well today. She said she did not want to talk because of the effort it required to talk and breathe at the same time. Resident #103 did not answer the surveyor's question regarding her pain level.
On 12/9/10 at 11:15 AM, the surveyor requested copies of November and December 2010 MARs, TARs and narcotic logs for Residents #100, 101, 102, and 103. At 2:55 PM on 12/9/10, the surveyor again requested copies of the current MARs, TARs, and narcotic reconciliation sheets for sample residents. At the time of the survey exit on 12/9/10 at 5:15, these documents had not been made available to the surveyor. ( )
F281G · Actual harm, isolated This citation pertains to Intake #: MI 968.
Based on observations, interviews, and records review, the facility failed to provide wound care in accordance with facility policies for three of four sample residents with wounds (#100, 101, and 104), resulting in severe pain, greatly increased potential for local and systemic infection, immobility, depression, low self esteem, isolation, and feelings of abandonment.
Findings:
Upon review of the facility's "Skin Practice Guideline", dated 7/2008, the surveyor noted that the policy was inconsistently followed in regard to care of residents of the facility. The standards set forth in the "Skin Practice Guideline" include:
1. Initial Evaluation-the Guideline sets forth nine risk factors associated with wound development that are to be evaluated using the Nursing Admission Evaluation;
2. Predicting Pressure Sore Risk-The Guideline states that the Braden Scale for Predicting Pressure Sore Risk is to be used for each resident upon admission, and weekly for four weeks after admission, then quarterly, or more frequently if needed.
3. Medical Care Initiative-The Guideline states that residents, who have an alteration in skin integrity, are to be evaluated by a designated member of the wound team within 24 hours of admission, or within 24 hours of development of a new wound, to determine the etiology and type of wound that is present.
4. Wound Treatment-The Guideline states that the member of the wound team who evaluates the wound will "collaborate with" the physician or the physician's designated advanced practice nurse to obtain and initiate orders for treatment of [REDACTED].
5. Documentation of the Wound-The Guideline states that a PUSH Tool is used to document pressure sores in combination with "a comprehensive evaluation" in the resident's clinical record, including these observations that are not included in the PUSH Tool: "depth of the wound, appearance of surrounding skin, presence and location of tunneling and undermining, evidence of infection, and pain"; a Skin alteration Record is to be used for wounds other than pressure sores.
6. Initial Plan of Care-The Guideline states that the initial plan of care is developed upon completion of the wound evaluation, individualized to meet the resident ' s unique needs, and includes interventions for: support surfaces, turning & positioning, incontinence management, referral to dietitian, pain management, referral to therapy, and treatment as ordered;
7. Skin Management-The Guideline states that the wound management team re-evaluates pressure sores weekly, using the PUSH tool and non-pressure sore wounds as clinically indicated, using the Skin alteration Record and documenting a comprehensive evaluation in the resident's clinical record including: appearance of surrounding skin, presence and location of tunneling or undermining, evidence of infection, pain, and depth.
Resident #100:
According to the admission record, Resident #100 was an [AGE] year old man, who was admitted to the facility on [DATE] for physical rehabilitation following surgery. Resident #100 was diagnosed with [REDACTED].
According to the admission MDS, dated [DATE], Resident #100 required extensive assistance from one staff member to complete his ADLs including moving about in bed, transferring into and out of bed, moving about the facility in a wheelchair, bathing, dressing, toileting, and eating.
The plan of care for prevention of wounds, dated 10/25/10, noted that Resident #100 had a Braden score of 16, placing him in the a mild risk category. Interventions listed on the wound prevention plan of care included: 1) Administer preventive treatment as ordered by physician; 2) Apply moisturizers to skin as needed; 3) Barrier cream to perineal area as needed; 4) Check for incontinence and provide incontinence care prn; 5) Dietetic consul/evaluation prn; 6) Encourage and assist to reposition as needed based upon patient ' s needs; 7) Encourage consumption of all foods especially high protein ones and all fluids provided; 8) Limit prolonged elevation of the head of the bed unless clinically indicated; 9) Monitor laboratory results per physician orders [REDACTED].
A plan of care for treatment of [REDACTED]. The interventions listed on this plan of care were exactly the same as the 15 interventions listed on the care plan above.
The Treatment Administration Record (TAR) listed several elements of the skin care plan of care: turn and position every two hours, suspend heels, and alternating pressure mattress. There were no entries in the TAR next to these care plan elements, to signify compliance with each one.
There was a second Braden scale was completed on 10/30/10, with a score of 15, categorizing Resident #100 as "low risk". There were no other competed Braden scale forms in Resident #100's clinical record, when according to policy, there should be weekly Braden assessments for 4 weeks.
There was no Skin Alteration Record completed for the skin shear wound on Resident #100's buttocks.
Nurses' Notes, dated 11/19/10, documented "four small open areas on scrotum". There was no Skin Alteration Record for these wounds. There was no further mention of these wounds in Nurses' Notes or any other place in the clinical record, although it was noted that Resident #100 was incontinent of urine.
Resident #100 was discharged from the facility to is daughter's home on 12/3/10.
Resident #101:
According to the admission record, Resident #101 was a [AGE] year old woman, who was transferred to the facility from another long term care facility on 10/18/10. Resident #101's diagnoses included [MEDICAL CONDITION] (MS-a progressively [MEDICAL CONDITION] disease of the nerves that control muscle movement), and depression.
The admission history and physical examination closed decubitus ulcers (pressure sores)".
According to the admission MDS, dated [DATE], Resident #101 was completely dependent on facility staff members to complete her activities of daily living. She needed assistance to turn in bed, to get into and out of bed, to move about the facility in a wheelchair, to prepare her meal tray, to bathe and dress, to toilet, and for grooming.
According to the MDS initial skin assessment, dated 10/19/10, Resident #101 had a stage 2 pressure sore on the posterior aspect of her left thigh and another stage 2 pressure sore on her left heel. The pressure sore on her left thigh was not measured. The pressure sore on her left heel was measured as 1.0 cm by 1.0 cm. The additional information on the Braden assessment stated that Resident #101 had 1) limited sensory perception, 2) very moist skin, 3) very limited mobility as she was confined to bed and unable to change positions independently, 4) "adequate" nutrition, eating over half of most meals, including four daily servings of protein, and 5) a potential problem with friction and shear as Resident #101 had to be moved in bed by others, creating friction with the sheets. The resulting score of 13, placed Resident #101 in the moderate risk category for the development of pressure sores.
The plan of care for prevention of pressure sores, dated 10/28/10, listed these interventions: 1) Apply moisturizers to skin as needed; 2) Barrier cream to perineal area as needed; 3) Check for incontinence and provide incontinence care prn; 4) Dietetic consult/evaluation prn; 5) Encourage and assist to reposition as needed based upon patient's needs; 6) Encourage consumption of all foods especially high protein ones and all fluids provided; 7) Limit prolonged elevation of the head of the bed unless clinically indicated; 8) Monitor laboratory values per physician orders [REDACTED].
There was a second skin care plan of care for Resident #101, dated 10/19/10, to address measures to restore skin integrity to stage 2 pressure sores. The interventions on this plan of care were: 1) Administer [MEDICATION NAME] (pain medication) per physician orders [REDACTED].) Monitor for and report any evidence of infection, such as purulent drainage, swelling, localized heat, increased pain, etc and notify physician prn; 10) Monitor for and report any new discoloration, open areas, bruises, skin tears, redness, observed during care and notify physician as needed; 11) Monitor for and report any significant weight fluctuations; 12) Monitor laboratory results per physician orders [REDACTED]. Eight of these interventions were the same as eight of the interventions listed in the first plan of care, above, dated 10/28/10. This plan of care was used as a supplement to the 10/28/10 plan of care and did not replace it.
No PUSH Tools were found in the clinical record for the pressure sore on Resident #101's left heel or the pressure sore on the posterior aspect of her left thigh. The surveyor requested copies of Resident #101's November and December wound care sheets from the facility administrator on 12/9/10 at 3:50 PM. No wound care sheets were received by exit on 12/9/10 at 5:15 PM.
On 10/19/10, Resident #101's admitted , a Skin Alteration Record was created for 2 blisters on Resident #101's left inner thighs, one measuring 2.0 x 1.0 cm and the other measuring 0.5 cm x 1.4 cm. According to the Skin Alteration Record, there was no drainage from either of these blisters and the surrounding skin appeared to be "normal". These two blisters were re-evaluated on 11/6 and documented as "drying", with no drainage and no alteration to the skin around the blisters. There was no indication that the physician was notified of the appearance of this blister. On 11/16/10, these two blisters were documented as "dried" with no drainage and no change to the appearance of the surrounding skin. On 11/23/10, the Skin Alteration Record noted that these blisters were "closed" and the treatment had been discontinued.
Also on 10/19/10, another Skin Alteration record was created for another blister on Resident #101's right thigh. There were no measurements given for this blister, which was described as fluid-filled and "dark pink" with reddened skin surrounding the blister. The blister had no drainage, but was painful. There was no notification that the physician was notified of the emergence of this blister. On 11/6/10, this blisters was re-evaluated and described as "drying" with no drainage. On 11/16/10, the right thigh blister was described as "dried", with no drainage and normal surrounding skin. On 11/23/10, the right thigh blister was described as "clear" and it was noted that treatment had been discontinued.
A new Skin Alteration Record was created two days later, on 10/28/10, documenting that Resident #101 had a new blister on the left side of her abdomen. This blister was measured as 6.0 cm by 3.0 cm. There were no characteristics documented on 10/28/10. There was no indication that the physician was notified of the emergency this new blister, the fourth in ten days. On 11/6/10, this blister was described as "intact purple blister", with no drainage and normal-appearing skin surrounding the blister. On 11/16, the abdominal blister was described as a "dried blister" without drainage and normal-appearing skin surrounding it. On 11/23/10, it was noted that treatments for this blister were discontinued on 11/22/10.
A third plan of care for Resident #101's skin care was created on 10/28/10. This plan of care identified the emergence of blisters on Resident #101's left abdomen, left thigh, and left arm, as well as a stage 1 pressure sore on her right heel. The new blister on Resident #101's left arm was not documented on a Skin Alteration Record. The interventions on this plan of care read: 1) Administer treatment per physician orders; 2) Avoid wearing of constrictive clothing or clothing which irritates skin; 3) Check for incontinence and provide incontinence care prn; 4) Encourage and assist as needed to turn and reposition; 5) Monitor for and report any [MEDICAL CONDITION] noted during care; 6) Monitor for and report any evidence of infection, such as purulent drainage, swelling, localized heat, increased pain, etc and notify physician prn; 7) Notify physician and family/responsible party of skin condition; and 8) Suspend heels as able. There were no Skin Alteration Records created for the blisters described in this plan of care on Resident #101 ' s left thigh and left arm. All 8 of these interventions were listed on the second 10/19/10 plan of care. The 10/28/10 plan of care was used as a supplemental plan of care and did not replace the two plans of care that were developed on 10/19/10.
The second Braden scale, which was to be completed on 10/26/10, was dated 11/8/10. Resident #101's score on this Braden was 17, low risk. The assessment differed from the first Braden scale: 1) Sensory perception was scored as "no impairment", rather than as on the 10/19/10 Braden, which was scored as "limited sensory perception"; 2) Skin was noted to be "rarely moist", rather than "very moist" as it was scored on the 10/19/10 Braden; 3) Resident #101's activity level was changed from bedfast to chairfast; 4) Mobility was scored as "slightly limited" rather than "very limited"; 5) Nutrition was scored as "probably inadequate as she consumed roughly half of the meals provided to her" rather than "adequate" because she ate over half of most meals, including four daily servings of protein; 6)Friction and shear were consistently listed as a "potential problem".
The third Braden skin assessment, due on 11/2/10, was conducted on 11/15/10, scoring Resident #101 as 13, moderate risk. This assessment scored Resident #101 as: 1) Sensory perception-"no impairment"; 2)Moisture was described as "Very moist"-the same score as the 10/19/10 assessment; 3) Mobility was scored as "completely immobile", the same as the 10/19/10 assessment; 4) Activities remained scored as "bedfast"; 5) Nutrition was again scored as "Adequate", consistent with th 10/19/10 assessment; and 6) Friction and shear were again listed as an actual problem, consistent with the 10/19/10 assessment.
On 11/15/10, a fourth plan of care for Resident #101's skin care was created in response to three new superficial openings on her right buttock. Interventions listed for this plan of care were: 1) Administer treatment per physician orders; 2) Check for incontinence and provide incontinence care prn; 3) Dietetic evaluation; 4) Encourage and assist as needed to turn and reposition; 5) Monitor for and report any evidence of infection such as purulent drainage, swelling, localized heat, increased pain, etc. 6) Notify physician prn; and 7) Special mattress/cushion on bed/wheelchair. All of these interventions were also on the second 10/19/10 plan of care and the 10/18/10 plan of care.
The fourth Braden scale, which was due on 11/9/10, was dated 11/17/10. this assessment identified a new pressure sore on Resident #101's left buttock. This pressure sore was measured as 3.0 cm x 2.0 cm. No additional characteristics were documented for this pressure sore. No PUSH Tool was identified for this unstaged pressure sore on Resident #101's left buttock.
An undated Skin Alteration Record identified a new blister on Resident #101's left leg at the inner aspect of her knee. This blister was measured as 3.0 cm by 2.0 cm. There was a notation that there was no drainage from the left knee blister and the surrounding skin was "normal appearance". It was noted to be painful. There was no evidence that the physician was notified of the emergence of this blister. On 11/6/10, the left knee blister was described as "drying", with no drainage and "normal appearing" skin surrounding the blister. The left knee blister was noted to be painful. On 11/16/10, the left knee blister was described as "dried", with no drainage and normal looking skin surrounding the blister. A notation on 11/23/10 stated that treatment had been discontinued for this blister.
Another undated Skin Alteration Record identified three new blisters on Resident #101's left hip. The area covered by all three blisters was measured as 6.0 cm by 3.0 cm. The blisters were documented as "painful". There were no other characteristics of these blisters documented. On 11/16/10, these blisters were described as "dried", with no drainage and "normal appearing" skin surrounding them. On 11/23/10, the notation was that treatments to these blisters had been discontinued. Again, there was no evidence that the physician had been informed about the appearance of these three blisters.
On 12/8/10 at 1:35 PM, the surveyor observed facility staff as they changed Resident #101's wound dressings. The first wound change was to a cluster of five blisters on Resident #101's right thigh, just above her knee. All five blisters were drying. One appeared to be crusted over. Resident #101 said these blisters did not hurt her. The second wound change was to a pressure sore located on Resident #101's left buttock. The wound consisted of pink tissue surrounded by beefy, red tissue. The third dressing was to the stage 2 pressure sore on Resident #101's right heel. This wound was pink at the center with white tissue surrounding the wound. The fourth dressing was to a blister on the front aspect of Resident #101's left knee. This blister appeared to be dried. The fifth dressing change was for a blister on the front aspect of Resident #101's right ankle. This blister was pink and filled with fluid. The sixth dressing change was for a cluster of blisters on Resident #101's right shoulder. There were five dried blisters in this cluster. A new open area was identified on Resident #101's back, half way between the midline and her side. Resident #101 denied any pain associated with the blisters and pressure sores. Resident #101 complained of very severe pain when she was turned and when her legs were moved to turn her providing access to these areas so they could be re-dressed. There were no PUSH Tools or Skin Alteration Records presented for any of the wounds dressed. There was no evidence that any of the blisters had been reported to the attending physician.
At the completion of Resident #101's dressing changes, an interview was held with nurse #9, who changed Resident #101's dressings. Nurse #9 said she had been working part time at the facility for several years. According to Nurse #9, the facility has no dedicated wound nurses or treatment nurses. The changing of dressings is included in each nurse's assignment for her shift for each resident with wounds in her assignment.
A review of Resident #101's clinical record did not reveal any physician progress notes [REDACTED].
During an interview with the director of nursing on 12/9/10 at 1:50 PM, the director of nursing said the facility's "interdisciplinary" Wound Team was comprised of CDC's (unit managers), the assistant director of nursing, and herself. Upon questioning, the director of nursing said there were no physicians, therapists, or dietitians on the facility's Wound Team. The director of nursing said the Wound Team reviews the PUSH tools created by staff nurses. According to the director of nursing, Resident #101 had all of her current pressure sores when she arrived at the facility on 10/19/10. The director of nursing did not mention that one pressure sore, located on Resident #101's left buttock and identified on the 11/17/10 Braden assessment, developed after admission. The director of nursing said she had not personally observed Resident # 101's wounds. The director of nursing said she was aware of the continual emergence of blisters on Resident #101's skin. The direct of of nursing was not able to provide a date when the physician was made aware of the emergence of any of Resident #101's blisters. She said there had been no [DIAGNOSES REDACTED].
Resident #104:
According to the admission record, Resident #104 was a [AGE] year old woman, who was admitted to the facility on [DATE] following hospitalization for a fractured pelvis, sustained when she fell at home prior to admission, and [MEDICAL CONDITION]. Another of Resident #104's diagnoses is [MEDICAL CONDITION] ([MEDICAL CONDITION]-a condition marked by airway resistance, making it difficulty to breath out).
According to Resident #104's plan of care, she is very short of breath and requires assistance from staff members to move about in bed, to get into and out of bed, to move about the facility, to toilet, bathe, dress, and eat.
Resident #104's admission nursing assessment, dated 11/9/10, documented that she had a pressure sore on her coccyx at admission, measuring 3.5 cm by 1.0 inches (2.5 cm). Another pressure sore was documented as being slightly to the left of the one described above. The second pressure sore was measured at 0.5 by 0.2 cm. Both pressure sores were described as having a scant amount of serosanguinous drainage. Neither one was staged. A Braden skin assessment was completed with the nursing assessment. The items scored were: 1) Sensory perception: slightly limited sensory perception, 2) Moisture: rare moisture, 3) Activity: walking short distances each day, 4) Mobility: slightly limited, 5) Nutrition: adequate-eats over half of her meals, and 6) Friction/Shear: potential problem-needs assistance to change position, causing skin to scrape across sheets. Her total score was 18, placing her in the low risk category for the development of pressure sores.
Resident #104 returned to the hospital on on 11/10/10 for treatment of [REDACTED].
According to Resident #104's admission nursing assessment, dated 11/27/10, Resident #104 had a stage 2 pressure sore on her coccyx. The skin surrounding the wound was described as "reddened". There were no measurements given. The Braden assessment, dated 11/27/10, was scored as: 1) Sensory Perception-no impairment, rather than "slightly limited" as it was scored on 11/9/10; 2 Moisture-"occasional" rather than "rare" as it was scored on 11/9/10; 3) Activity-chairfast, a change from the 11/9/10 assessment of "walking short distances each day; 4) Mobility-remained "slightly limited", consistent with the 11/9/10 evaluation; 5) Nutrition-"probably inadequate" rather than 11/9/10's score of "adequate"; and 6) Friction/Shear-was scored as an actual problem, a change from the 11/9/10 assessment, evaluation risk of skin shear from friction as a "potential problem". Resident #104's Braden score on 11/27/10 was 15, a low risk category.
A second Braden assessment, dated 12/8/10, described Resident #104's wounds as being stage 2 pressure sores located at the coccyx (tailbone). Resident #104's Braden score on 12/8/10 was not calculated. Risk factors were identified as: 1)requires staff assistance to move, 2) confined to a bed/wheelchair all or most of time, 3) needs specialized mattress/seat cushion, 4) requires regular schedule for turning, 5) slides down in bed, and 6) persistently wet from incontinence or wound drainage, immobile, cognitive loss, and poor nutrition.
The plan of care developed for Resident #104 on 11/19/10 to address her pressure sores listed these interventions: 1) administer [MEDICATION NAME] per physician orders [REDACTED]. [MEDICAL CONDITION] noted during care; 8) Monitor for and report any new discoloration, open areas, bruises, skin tears, redness observed during care and notify physician prn; 9) Monitor for and report any significant weight fluctuations; 10) Monitor laboratory test results per physician orders [REDACTED]. as needed; and 22) Wrap/pad oxygen cannula.
A second plan of care for maintaining Resident #104's skin integrity was created on 12/8/10. The interventions for this care plan were: 1) apply moisturizers to skin as needed; 2) barrier cream to perineal area as needed; 3) Dietetic consult/evaluation prn; 4) Encourage and assist to reposition as needed based upon patient's needs; 5) Encourage consumption of all foods especially high protein ones and all fluids provided; 6) Limit prolonged elevation of the head of the bed unless clinically indicated; 7) Monitor laboratory results per physician orders [REDACTED]. Check around ears/nasal passages for pressure areas with care and report to MD if found. All but one of these interventions were already active in the 11/19/10 plan of care.
There were no PUSH Tools identified for Resident #104. Nurses' Notes, dated 11/27/10, gave the measurement of the stage 2 pressure sore on Resident #104's coccyx as 1.5 inches (4.0 cm) by 2.8 inches (7.2 cm) for the lower wound and 3.5 inches (9.0 cm) by 1.8 inches (3.5 cm). No wound characteristics were given. No other information was given in Nurses' Notes in regard to Resident #104's pressure sores.
On 12/9/10 at 11:15 AM, the surveyor requested copies of November and December 2010 MARs, TARs and narcotic logs for Residents #100, 101, 102, and 104. At 2:55 PM on 12/9/10, the surveyor again requested copies of the current MARs, TARs, and narcotic reconciliation sheets for sample residents. At the time of the survey exit on 12/9/10 at 5:15, these documents had not been made available to the surveyor.
As identified during this investigation, the facility failed to consistently implement its 2007 wound care policies. The facility does not have a functioning interdisciplinary wound care team, as described in the policies. There is no one person responsible for assuring that each resident's wound care meets the expectations set forth in the 2007 policies. While there may have been additional PUSH Tools and Skin Alteration Records created for the four sample residents, these records were requested, but were not made available to the surveyor. There was no evidence that newly emerging skin integrity issues were brought to the attention of the residents' attending physicians. There were no interdisciplinary interventions in the plans of care. There were multiple plans of care duplicating some or all of the same interventions, creating confusion for staff members. Interventions were not necessarily linked to actual or potential issues with residents' skin integrity. There was no system to assure accountability with standards for the frequency of wound assessment. There was no system to assure that ordered interventions were consistently initiated and that interventions made obsolete by changes in residents' conditions were updated. There was no system to measure the effectiveness of any interventions or treatments provided for residents with wounds. ( )