NYS Health Profiles
Find and Compare New York Health Care Providers
NYS Health Profiles
Find and Compare New York Health Care Providers
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 7, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview during the abbreviated survey (NY 901), the facility did not ensure residents with pressure ulcers or at risk of pressure ulcers received the necessary treatment and services, consistent with professional standards of practice, to promote wound healing, prevent infection, and prevent new ulcers from developing for 2 of 3 residents (Residents #1 and 3) reviewed. Specifically: -Resident #1 developed new pressure ulcers and there was no documented evidence that recommended treatment orders obtained or implemented timely and no documented evidence diagnostic tests were ordered or obtained timely. -Resident #2 developed a Stage 3 pressure ulcer on their coccyx and there was no documented evidence the registered dietitian reassessed the resident's nutritional needs. Additionally, the resident had a significant weight loss and there was no documented evidence the registered dietitian was made aware to reassess. Findings include: The facility's policy Weights, effective 2/2012 documented residents were weighed upon admission, weekly for 4 weeks after admission, readmission and monthly thereafter to establish a weight patter and monitor for changes. Re-weights were to be obtained for any discrepancies, the Interdisciplinary Team reviewed possible causes of weight change and initiated appropriate interventions, and weight loss or gain of 5% in one month and/or 10% in 6 months must be reported to the registered dietitian, physician, and Minimum Data Set coordinators to review for possible significant change in status. The facility's policy Medication: Physicians Orders Management, revised 3/24/2022 documented outside consultants wrote their orders and details of their visit on a consultation form or in their company documentation format. Outside consultants' documentation and orders would be scanned or uploaded into the resident's medical record. The orders and visit description would be reviewed by the resident's primary care provider, orders would be implemented and written by an in-house provider as deemed appropriate. 1) Resident #1 had [DIAGNOSES REDACTED]. The 9/26/2023 Comprehensive Care Plan documented the resident was at risk for skin breakdown related to immobility, deconditioning and incontinence. Interventions included keep skin clean and dry, pressure relieving device in wheelchair and on bed, and skin team to monitor weekly. The 3/26/2024 at 5:24 PM Licensed Practical Nurse #4 Manager note documented the resident had a wound to the left buttocks that was 4 centimeters x 4. 3 centimeters and the resident also had multiple unmeasurable sores to the right side of buttocks. The registered nurse assessed, and orders were obtained. The 3/26/2024 physician orders [REDACTED]. To the right side of buttocks, apply [MEDICATION NAME] (protective barrier cream) three times daily for wound. The 3/29/2024 Wound Physician #2 note documented the resident had left buttock moisture associated skin damage (skin problem that occurs from repeated exposure to bodily fluids) that was 4 centimeters x 11 centimeters by 0. 2 centimeters. The plan was to use calcium alginate (wound treatment) with a bordered dressing daily. The 4/1/2024 physician order [REDACTED]. The 5/3/2024 updated Comprehensive Care Plan documented the resident had a wound to the left buttock. Interventions included treatments as ordered, monitor that dressing was intact, and obtain and monitor lab work and diagnostics as needed. The 5/17/2024 Wound Physician #2 note documented the resident had a Stage 3 (full thickness loss of tissue) sacral (triangular bone in the lower back between two hipbones of the pelvis) ulcer that was 4 centimeters x 5 centimeters x 0. 2 centimeters and was 30% necrotic (non-viable tissue). The plan was to use calcium alginate and [MEDICATION NAME] (wound treatment) covered with a foam silicone bordered dressing daily. The 5/17/2024 physician order [REDACTED]. There was no documented evidence the treatment order was updated to apply to the sacral ulcer as documented in the wound physician note. The 5/24/2024 at 1:35 PM Wound Physician #2 note documented the resident had: -an Unstageable sacral ulcer that was 4 centimeters x 2. 5 centimeters x 0. 2 centimeters. The plan was to continue calcium alginate and [MEDICATION NAME] covered with a foam silicone bordered dressing daily. -a Deep Tissue Injury (injury of underlying soft tissue from pressure or shear) on the left ischium (lower bone of the pelvis) that was 4 centimeters x 4 centimeters and was intact with purple discoloration. The plan was for [MEDICATION NAME] paste (wound treatment) every shift. -a Deep Tissue Injury of the right ischium that was 6 centimeters x 2 centimeters and was intact with purple discoloration. The plan was to use [MEDICATION NAME] paste every shift. The 5/24/2024 physician orders [REDACTED]. There was no documented evidence of an order for [REDACTED]. 2024. The 5/29/2024 Attending Physician #3 note documented the resident's white blood cell count (potential indicator of infection) was up a bit. The resident was followed by wound care for a very significant sacral ulcer. No changes were made today. The 5/31/2024 at 1:35 PM Wound Physician #2 note documented the resident had: -an Unstageable sacral ulcer that was 4 centimeters x 2 centimeters x 0. 2 centimeters. The wound had 100% slough (non-viable tissue). The plan was to change the treatment to Santyl (wound treatment used to remove damaged skin), use a gauze sponge dressing moistened with saline and cover with a foam silicone bordered dressing daily. -an Unstageable left ischium ulcer that was 5 centimeters x 7 centimeters x 0. 2 centimeters. The wound was 50% necrotic, 50% slough. The plan was to change to Santyl, use a gauze sponge soaked in saline and cover with a bordered dressing daily. -an Unstageable right ischium ulcer that was 3 centimeters x 6 centimeters x 0. 2 centimeters. The wound was 100% necrotic. The plan was to continue [MEDICATION NAME] paste every shift, and add Santyl with saline soaked gauze pad daily, There was no documented evidence the resident's sacral ulcer treatment was changed from [MEDICATION NAME]/calcium alginate to Santyl as recommended by the wound physician and there was no documented evidence of a treatment order for the right and left ischium's as recommended. The 6/5/2024 at 7:22 PM Registered Nurse #5 note documented they spoke with the on-call provider as the resident had a temperature of 101. 6 and were lethargic. They observed the resident's sacral wound with purulent (pus) drainage. New orders were obtained for [MEDICATION NAME] (antibiotic) 100 milligrams twice daily for 7 days. Wound culture and labs ordered. The 6/5/2024 physician order [REDACTED]. There was no corresponding provider note. There was no documented evidence a wound culture was obtained. The 6/7/2024 Wound Physician #2 note documented the resident had: -an Unstageable sacral ulcer that was 2. 6 centimeters x 2. 7 centimeters x 0. 2 centimeters. The plan was to continue Santyl. -an Unstageable left ischium ulcer that was 4. 5 centimeters x 9. 3 centimeters x | Plan of Correction: ApprovedFebruary 3, 2025 1. Residents #1 and #3 are no longer residents of the facility. The nurse managers for residents #1 and #3 were provided written education for not following the facilities policy in regard to orders management/transcriptions and weight loss. The dietician was also provided written education on the facility weight loss and wound management policy. 2. A facility wide audit was completed on 12/20/2024 of all residents weights, any identified weight loss was confirmed with a reweight and communicated via documentation in the resident records to the medical provider, dietitian, and then reviewed with MDS. There were no other residents identified with unaddressed weight loss, finding no other residents having been impacted by the deficient practice. 3. A facility wide audit was conducted on 12/06/2024 that included a head-to-toe skin check on all residents to identify skin issues that may have not been documented or with wound care orders, this includes an audit of all residents being followed by an outside wound care service, ensuring that all orders from the most recent visit were transcribed as written. The audit identified that no other residents were impacted. 4. The facility medical orders management policy (#6011) was reviewed, finding it to be appropriate and not followed by staff resulting in deficient practice. The facility weight policy (#8220) was reviewed, found to be appropriate and not followed by staff, resulting in the deficient practice, the skin management policy (#8162) was reviewed and revised to clarify nurse managers expectations of: * following resident active wounds by documenting the results of the visit in the residents record and notifying the medical provider and dietitian. *the required immediate review of the outside wound consultants visits to include transcribing the consultant orders the same day as the visit. *Add a progress note acknowledging that they completed the transcriptions, documentation, and in house medical/dietitian notification of the visit. 5. Education has been given to the nurse managers and DON on medication orders management/transcriptions, consult visits, weight changes, and skin management policy updates. 6. The DON is completing weekly audits while holding a weekly skin and weight meeting with MDS, nurse managers, and the dietitian present. The audit includes: A. Keeping a running list of all active wounds in the facility on a spreadsheet B. Checking that all wound orders including consultant visits for the residents are present and correct weekly on the spread sheet. C. Checks that the care plans are present and appropriate for all active wounds. D. Ensures dietitian and medical notifications are present in the record from the nurse managers. E. That the dietitian has completed a resident assessment within 72 hours of any new wounds or confirmed weight loss and that recommended supplements are ordered as found appropriate. 7. The deficiency will be brought to the next QAPI meeting and reviewed with the committee, the weekly audit results will also be brought to the monthly QAPI meeting until 90 days of 100% compliance is obtained. The weekly skin and weight meeting with the IDT will remain indefinitely as a new facility process to ensure continued compliance. 8. Weekly audit of all dietitian notes will be pulled and reviewed at the weekly wound and weight management meeting and brought to QA to ensure compliance that resident assessment was completed within 72 hours of any new wounds or confirmed weight loss. After 4 weeks we will move to monthly audits x 3 months. Then review with QAPI to determine the frequency going forward. 9. The DON/designee is responsible for the completion and compliance of this plan. |