Following are some of the deficiencies found during inspections of this nursing home on 2/13/09, 4/25/08, 3/27/08 and 6/15/07. These Reports and others (12/12/06 – 8 pages, 6/28/06 – 18 pages and 5/26/06 – 37 pages) can be found at www.arknursinghomeinspectiondeficiencies.com.
Inspection on 2/13/09 (29 pages) 1. PRESSURE SORES: . . .the facility must ensure that . . . a resident having pressure sores receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing . . . the facility failed to ensure a wound treatment was performed using aseptic technique [free from or keeping away from disease producing or putrifying microorganisms] and a pressure relieving device was in use in a wheelchair to promote healing for Resident #4 with pressure sores. . . Resident #4 . . . had pressure relieving devices for the chair and the bed. a. A Physician telephone order dated 1/8/09 documented: “Apply wound gel and dry drsg [dressing] to buttocks Q [every] day until healed.” b. The Plan of Care dated 1/8/09 documented: “Potential for pressure sores related to decline Physical health, decreased mobility, use of restraint and incontinence. Actual State II to coccyx.” c. On 2/9/09 p.m. and 5:10 p.m. and on 2/10/09 at 8:37 a.m. and 12:05 p.m., the resident was up in a wheelchair with a pelvic restraint on. There was not a pressure relieving device in the wheelchair. d. On 2/10/09 at 9:20 a.m., Registered Nurse #2 performed a treatment to the resident coccyx. . . . She did not change her glove between handling the soiled dressing and the clean dressing. Pages 13-15. 2. 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% . . . Page 27
Inspection on 4/25/08 (27 pages) 1. ACCIDENTS AND SUPERVISION: . . . the facility failed. . . to ensure side rails [S/Rs] were in working order to prevent accidents for . . . residents who utilized S/Rs for bed mobility and turning. The failed practices resulted in. . . injury . . . for Resident #1 who dislodged the S/R, fell out of the bed onto the floor and sustained a subdural hematoma. . . Page 3.
Inspection on 3/27/08 (18 pages) 1. PRESSURE SORES:. . .the facility failed to ensure a pressure relief device was utilized as ordered by the Physician for Resident #4 . . . a. The Physician order dated 9/28/07 documented, “Continue Pressure Relief with (Prato Boot) to L (left) heel.” c. On 3/25/08 at 8:10 a.m., the resident did not have a boot on her left foot. d. On 3/25/08 at 9:10 a.m., after CNA #4 and CNA #5 completed care, they did not put a heel protector or a boot on the resident. Pages 5-6.
Inspection on 6/15/07 (29 pages) 1. PRESSURE SORES: . . . the facility failed to ensure incontinent care was provided in a timely manner for Resident #5 . . . at risk for skin breakdown and/or pressure ulcers. . . and . . .had a history of pressure ulcers. c. On 6/11/07 the following observations were made: At 5:15 p.m., the resident was lying on her back in bed. The left side of her head was pushing against the side rail. The resident had been incontinent of a large amount of liquid stool. The incontinent pad that was under her buttocks was saturated and stained and the stain extended approximately 6 inches from her hips. The outer edge of the stain was marked with an ink-pen. The room had a foul odor. The door to her room was open and the odor could be identified from the hallway outside of the resident’s room. At 5:30 p.m., CNA #1 was feeding the resident. The right side of her head remained pushed up against the side rails. The CNA made no attempt to re-position the resident. The odor from the liquid stool was present. At 6:00 p.m. LPN #1 was leaving the resident’s room. The resident had been repositioned with her head away from the side-rail and the resident was aligned in bed. The ink mark remained and the watery stool stain had extended beyond the pen mark that was made at 5:15 p.m. The odor in the room and hallway was still present. At 6:40 p.m. the resident was still lying on the stool soaked pad. The first ink mark remained and a second ink mark was made on the outer edge of the stain which was now approximately 9 inches from the resident’s hips. The foul odor remained. At 6:50 p.m. CNA #1 and CNA #6 entered the room pushing the resident’s roommate in a wheelchair. . . The CNAs transferred the roommate into the bed next to the door. The foul odor was present from the hallway and in the room. The CNAs did not check resident #5 and left the room. At 7:15 p.m., CNAs #1 and #6 walked down the hallway past the resident’s room and continued down the hall. The foul odor was still present in the hallway. At 7:45 p.m. LPN #1 entered the room to give the roommate medication. The foul odor was still present in the room. The LPN did not check Resident #5. At 7:55 p.m. Registered Nurse (RN) #1 entered the room, then turned around and left. At 7:57 p.m. RN#1 returned to the resident’s room. “Oh my goodness,” then left the resident’s room. At 8:10 p.m. CNAs #1 and #6 returned to provide incontinent care. CNA #3 entered the room to assist at 8:15 p.m. When the resident’s sheet was removed, the ink marks remained on the incontinent pad and the outer edges of the stain was now dry and a brown ring was present. At 8:35 p.m. after CNA #3 completed the incontinent care of the Petri area CNA #1 patted the resident dry with a white towel between her legs. When the towel was lifted from between her legs, yellow stool was present. The CNAs did not clean the perineum again. The resident was then turned on her side and the CNAs cleaned the stool from the resident’s buttock. Pages 8-11.
