The Grand Rehabilitation and Nursing at River Valley
March 30, 2017 Complaint Survey

Standard Health Citations

FF10 483.10(g)(14):NOTIFY OF CHANGES (INJURY/DECLINE/ROOM, ETC)

REGULATION: (g)(14) Notification of Changes. (i) A facility must immediately inform the resident; consult with the resident?s physician; and notify, consistent with his or her authority, the resident representative(s) when there is- (A) An accident involving the resident which results in injury and has the potential for requiring physician intervention; (B) A significant change in the resident?s physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); (C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or (D) A decision to transfer or discharge the resident from the facility as specified in §483.15(c)(1)(ii). (ii) When making notification under paragraph (g)(14)(i) of this section, the facility must ensure that all pertinent information specified in §483.15(c)(2) is available and provided upon request to the physician. (iii) The facility must also promptly notify the resident and the resident representative, if any, when there is- (A) A change in room or roommate assignment as specified in §483.10(e)(6); or (B) A change in resident rights under Federal or State law or regulations as specified in paragraph (e)(10) of this section. (iv) The facility must record and periodically update the address (mailing and email) and phone number of the resident representative(s).

Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: March 30, 2017
Corrected date: May 30, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews and record review during an abbreviated survey (Complaint # NY 334) the facility did not ensure that residents' legal representatives were informed of a need to alter treatment modalities. Specifically, the facility or physician did not obtain consent or notify families when the wound care physician performed wound debridement on 10 (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10) of 10 residents reviewed for wound care. There was no evidence that the residents' families were notified of the need to perform wound debridement by the wound care physician. Complaint #: NY 334 The findings are: A review of 10 other residents' medical records did not reveal any documented evidence that the resident's family were notified of the need to alter treatment modalities. 10 of 10 residents reviewed between [DATE] and [DATE] had wound debridement performed by the wound care physician, with no documented evidence that resident, and or family members were notified or consents were obtained per policy and procedures for wound debridement. Resident # 1 was an [AGE] year-old female who was admitted to the facility on [DATE]. Her admitting [DIAGNOSES REDACTED]. The most current MDS (Minimum Data Set; a resident assessment tool) dated [DATE] documented the resident's cognition was moderately impaired. Resident has a responsible party who is involved with resident's care. It further documented that resident required extensive assist of one person for bed mobility, dressing, eating, toileting and personal hygiene. Resident's Medical Orders for Life - Sustaining treatment (MOLST) dated [DATE] documented that resident is on comfort measures only, DNI/ DNR (do not intubate/ do not resuscitate) do not send to the hospital unless pain or severe symptoms cannot be otherwise controlled, no feeding tube, no I/V fluids, do not use antibiotics. Review of the Hospital record / assessment which was dated [DATE] documented that the resident had a large infected heel decubitus with probable calcaneal osteo[DIAGNOSES REDACTED] by x-ray. Debridement would be futile. The only reasonable surgical option would be an above- knee amputation. Below- knee amputation is not recommended in this situation because resident would not ambulate with a prostatic, and it has lesser chance of healing. Review of the Resident's Admission History and Physical dated [DATE], the Attending Physician documented that resident was a [AGE] year-old female with primary [DIAGNOSES REDACTED]. Review of the facility Policy and Procedure, Informed consent for invasive procedures, documented the purpose of the informed consent is to give the resident, and when appropriate the responsible party, a clear and concise explanation of: a) the resident's condition and any changes in the condition; b) any proposed treatment or procedures; and c) the potential benefit, risk and alternative of the proposed treatment or procedure. Once the family receives and understands this information they can make an informed choice and either consent or to refuse the proposed treatment. Review of the AmeriWound Policy (The wound consulting company that the facility has a contract with; the AmeriWound care physician comes every week to the facility) for Patient Consent to Treatment dated [DATE] documented, Purpose: Help to assure that all AmeriWound patients/legal representatives are informed and give consent to treatment with the appropriate signed documentation before certain types of surgical wound intervention procedures are performed. Definitions: (AmeriWound Intervention Procedures Requiring Signed Informed Consents to Treatments): Sharp debridement- The surgical removal of dead or necrotic tissue or foreign material from and around a wound to expose healthy tissue using any of the following sterile instruments: curette, scalpel, scissors, forceps. Review of [DATE] the provider pressure injury assessment wound consultant's (wound care physician) report documented, Initial visit: R Heel stage 4 wound measured 9.5 cm x 12 cm x 0 cm. Post debridement measurement 9.5 cm x 12 cm x 3.5 cm, area (length x width) 114 SQ cm. Instruments used: Scalpel, forceps. L heel wound 4.5 cm x 5 cm. Resident # 2 is a [AGE] year-old female who was admitted to the facility on [DATE]. Her admitting [DIAGNOSES REDACTED]. Her BIMS score of the MDS of [DATE] is ,[DATE]. No consent/ family notification found in the resident's medical record for the left heel debridement which was conducted on [DATE] by the AmeriWound care physician. Review of the provider pressure injury assessment and orders dated [DATE] documented as, left heel stage 4 pressure injury measured 2.5 X 3.0: post debridement measurement in cm, 2.5 X 3.0 X 0.5, area (length X width) 7.5 cm. Instrument used; scalpel. On [DATE] at 10 am, in an interview with RN #1 (Facility DON) she stated that the Resident #1 was only at the facility for 4 days, she was admitted on [DATE]. The debridement was done on [DATE] and resident expired in the facility on [DATE]. She further stated that she thought the wound care physician notified the family who were very involved with the resident, to obtain the consent before the debridement. On [DATE] at 12:40 pm, an interview was conducted with the facility social worker who stated that she didn't contact the family for any consent for the debridement. On [DATE] at 1:45 pm, an interview was conducted with the wound care physician. He stated that he works as a wound consultant for the AmeriWound Company. He further stated that he didn't call the family to inform about the procedure or to obtain the consent for the debridement. He stated that he walks with the wound team and if they ask him to debride any wound he does it. He further stated that he thought it's the facility's responsibility to obtain the consent from the family. He also stated that he doesn't know if his company (AmeriWound) has any policy for obtaining consent prior to the procedure. On [DATE] at 2:30 pm, an interview was conducted with the RN #2 (nurse manager) via telephone in the presence of the facility DON. RN #2 stated that she did the wound round with the wound physician and assisted him for the debridement, no one else was with them. She further stated that she always thought it was the responsibility of the wound care physician to inform the family and get the consent prior to the debridement. She also stated that she never called any family to obtain the consent for debridement. On [DATE] at 10 am, the facility Administrator was interviewed via telephone. He stated that he presumed everybody is doing what they are supposed to do. The Administrator further stated that he thought the wound care physician was following the protocol and he didn't know that the wound care physician was doing the debridement without notifying the family and obtaining the consent. On [DATE] at 2:45 pm, the Attending Physician was interviewed. The Physician stated that he didn't know that the wound consultant did the wound debridement without the family consent. He further stated that if he had any problem obtaining the consent, he should have notified the physician or the facility staff. 483.10 (b) (11)

Plan of Correction: ApprovedMay 18, 2017

Corrective Action -
1. The company that was contracted to provide wound care services was immediately notified about their physicians deficient practice. The MD from Ameri Wound received in service from their Supervisor regarding policies on obtaining consent for debridement.
2. The Director of Nursing in serviced the licensed nursing staff regarding obtaining consent for invasive procedures and containing consent from the responsible party when necessary.
3. Obtaining consent has been added to the curriculum for orientation for all new licensed nurses.
4. The format for wound rounds no longer involves an outside wound company.
5. Of the residents noted in this deficient practice all wounds are healing appropriately, have been discharged home, or have healed completely.
Residents At Risk For Same Practice -
1. All residents who require an invasive procedure whether independent in decision making or require their responsible party to make their decisions were identified as being at risk.
Systemic Changes -
1. All physicians providing services that may require invasive procedures in our facility were in serviced regarding facility policy about obtaining consent for each procedure.
2. The facility now utilizes an in house wound care team for all wound rounds led by a wound care certified nurse. All wounds requiring invasive procedures will be sent out for consultation.
3. Each RN Unit Manager will monitor all invasive procedures on their respective units and will ensure that consents are obtained prior to any procedure.
Monitoring Of Corrective Action -
1. The Director of Nursing and designee will be responsible to audit all invasive procedures performed in the facility to ensure compliance with facility policy.
2. The Director of Nursing will report their findings to the QA committee on a quarterly basis for one year.
Person Responsible And Date Of Completion -
1. The person responsible is the Director of Nursing.
2. The date of completion is 5/30/2017.