Inspection on 2/20/09 (30 pages) 1. QUALITY OF CARE: . . . The facility failed to ensure excoriated areas of skin were promptly identified and treated for . . . Resident #2. . . who had excoriated skin under the skin folds . . . g. On 2/18/09 at 2:15 p.m., . . . The Treatment Nurse stated she was done with treatments and this surveyor requested that the resident’s breast be lifted. The resident had a reddened area under both breasts . . The resident had excoriation, reddened skin with a yellow substance covering the majority of the reddened area, in the right axillary area extending from mid inner arm to mid chest area across the width of the right inner arm and the chest was the same width. The resident had excoriation, reddened area, under the left axillary area approximately 8 centimeters by 6 centimeters in size. The resident had excoriation, redness under the bilateral breast approximately 8 centimeters by 6 centimeters in size. The resident had excoriation, redness with bleeding, under the abdominal fold across the entire abdominal fold that was approximately 6 inches wide . . . There was excoriation, redness with one area that was bleeding, of the resident’s bilateral inner thighs across the front ½ of the thigh down to mid thigh level. . . On 2/20/09 at 3:25 p.m., the Treatment Nurse was asked, “Did you know about the excoriation under [Resident #2’s] breast and perineal area prior to the 2/18/09 body audit with me?” The Treatment Nurse stated, “No.” Pages 1,6-7.
2. PRESSURE SORES: . . the facility failed to ensure a pressure ulcer dressing on coccyx was free of feces for Resident #5. . . who had . . . Pressure Ulcer of Coccyx. The Quarterly MDS dated 1/14/09 documented the resident . . . had one Stage III pressure sore. . . On 2/17/09 at 7:15 p.m., CNA #10 was changing the bed linen. There was a dressing on the resident’s coccyx dated 2/16/09. The dressing had feces on the bottom fifth and under the bottom edge. There was also brown coloration on the lower buttocks and upper thighs. At 8:00 p.m., the dressing on the coccyx still had dried feces. Pages 11, 14-15.
3. MEDICATION ERRORS: . . The facility must ensure that it is free of medication error rates of five percent or greater. . . The medication error rate was 10.42% . . . Pages 20-21.
Inspection on 8/15/08 (23 pages) 1. ACTIVITIES OF DAILY LIVING: . . .the facility failed to ensure incontinent care was provided for Resident #11 . . . a. On 8/13/08 at 10:58 a.m., CNA #2 and #3 assisted the resident to stand, transferred the resident to the commode and pulled off the resident’s incontinent brief. CNA # 3 stated, “He’s wet. He’s sometimes incontinent.” The CNAs then put a clean incontinent brief on the resident, assisted him to stand and pulled up incontinent brief. Neither CNA cleaned the resident. The resident had a strong urine odor. The CNAs then pulled up the resident’s pants and transferred the resident back to the wheelchair. Both CNAs were asked if they were finished. They answered “yes,” washed their hands and left the room. Pages 1-2.
2. SANITARY CONDITIONS – FOOD PREP & SERVICE: . . . the facility failed to ensure dishes were clean, dried and free of food particles after washing and sanitizing, staff washed their hands after handling dirty items and before handling food or clean items, proper hand washing technique was used and the kitchen was free of insects. Page 19.
Inspection on 3/12/08 (11 pages) 1. NOTIFICATION OF CHANGES: . . . the facility failed to ensure a physician was consulted regarding changes in condition . . . when Resident #10 exhibited signs of respiratory distress . . . These failed practices caused or could have caused serious harm, injury, impairment or death to Resident #10 who was hospitalized and died of acute respiratory failure. Page 2.
Inspection on 11/9/07 (46 pages) 1. PRESSURE SORES: . . the facility failed to ensure turning and repositioning were provided at least every two hours . . . for Resident #5 . . . The facility also failed to ensure urine / feces were thoroughly cleansed from all areas of the resident’s skin to decrease the potential for skin breakdown for Residents #2 and #6 . . . Page 1
2. NUTRITION: . . . the facility failed . . . Resident #9 who experienced severe, unplanned weight loss . . . The Resident Weight records documented Resident #9’s weight as follows:
. . . On 11/6/07 . . . at 2:30 p.m., a re-weigh was requested . . . the resident’s weight was 158.4 pounds . . . On 11/6/07 at 2:50 p.m., the Plan of Care was again reviewed and copied. Handwritten interventions had been added to the Plan of Care. There was no date on these interventions to indicate when they were added to the Plan of Care. At 2:55 p.m. the Director of Nursing . . . stated she and the Nurse Consultant had updated the Plan of Care, “Today.”. . .As of 11/7/07 at 4:00 p.m., there was no assessment or reassessment . . . in the Dietary Progress Notes to ensure appropriate intervention were developed and implemented to prevent further weight loss. Pages 12, 13 - 17, 18, 21 and 22.
