Wayne County Nursing Home
November 2, 2016 Complaint Survey

Standard Health Citations

FF09 483.25(c):TREATMENT/SVCS TO PREVENT/HEAL PRESSURE SORES

REGULATION: Based on the comprehensive assessment of a resident, the facility must ensure that a resident who enters the facility without pressure sores does not develop pressure sores unless the individual's clinical condition demonstrates that they were unavoidable; and a resident having pressure sores receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: November 2, 2016
Corrected date: December 26, 2016

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews conducted during an Abbreviated Survey (complaint #NY 589) completed on 11/2/16, it was determined that for one (Resident #1) of three residents reviewed for skin conditions, the facility did not provide the necessary services to prevent the development of or promote the healing of pressure sores. The issues involved lack of communication regarding skin breakdown, lack of timely assessment, documentation, and treatment of [REDACTED]. Resident #1 was admitted with [DIAGNOSES REDACTED]. The Certified Nursing Assistant (CNA) Assignment Summary, effective on 8/14/16, directed TEDS (anti-embolism stockings to prevent blood clots) on in the morning and off in the evening and when in bed, place pillow under heels to elevate off bed. The weekly skin assessment, completed on 8/11/16 by Licensed Practical Nurse (LPN) #1, revealed no skin breakdown or skin related issues. The 24-hour reports for 8/14/16 and 8/15/16 provided no information related to the resident's right heel. A Nursing Progress Note, dated 8/16/16, revealed that LPN #1 was called to the resident's room to look at the resident's right heel. She noted a 4 centimeter (cm) x 4 cm intact black blister. The physician was notified and ordered skin prep and Allevyn heel cup (specialized dressing) to the right heel every three days. When interviewed on 9/22/16 at 10:00 a.m., the Compliance Officer/Registered Nurse (RN) stated that CNA #1 said she observed a reddened area on the resident's right heel on 8/14/16, reported the observation to LPN #3, but did not document the observation in the Stop and Watch (tool used to identify resident changes) or in Scores documentation as a staff concern per the facility policy. In an observation on 9/28/16 at 10:50 a.m., the resident's right heel had a wound that was black in color with no drainage, and measured 4 cm x 4 cm. Interviews conducted on 10/17/16 included the following: a. At 1:25 p.m., CNA #1 stated that she observed the resident's heels on 8/14/16 and noted redness, but did not document in the Stop and Watch or in Scores as a staff concern because the resident's heels are always pink/red in color. She said she reported the red heels to LPN #3. CNA #1 said when she cared for the resident on 8/16/16 in the morning, she noticed the resident had a right heel blister and reported her observation to LPN #3. CNA #1 stated the resident's heels were not on a pillow, when first observed in bed on 8/16/16. She said the resident is care planned to have her feet/heels elevated off of the mattress when in bed. b. At 1:45 p.m., LPN #3 stated that she was not made aware of the resident's right heel wound until after it was reported on 8/16/16. LPN #3 stated that the CNAs are expected to immediately report any changes in skin conditions. c. At 2:05 p.m., LPN #1 stated that on 8/16/16 at 8:45 a.m., CNA #1 reported a right heel blister and stated that the resident's right heel was red and pink on 8/14/16. LPN #1 stated that when she observed the resident on 8/16/16, the resident was in bed and her heels were on the mattress. LPN #1 said the resident is supposed to have a pillow underneath her feet/heels when in bed. LPN #1 stated she notified the RN supervisor at that time. When interviewed on 10/31/16 at 11:30 a.m., the RN supervisor stated that on 8/16/16, she assessed the resident's right heel and described the area as an intact blister unstageable pressure area measuring 4 cm x 4 cm with dark fluid noted. (10 NYCRR 415.12(c)(2))

Plan of Correction: ApprovedNovember 21, 2016

a) For Resident #1, skin treatment was initiated on 8/16/2016 and continued thoroughly until blister healed and skin was healthy and intact. Status of skin was monitored and reported. All staff interviewed during survey were immediately in-serviced on STOPANDWATCH tool, 24 hour report and skin assessments. 11/2/2016
b) All skin assessments will be reviewed for the last 30 days to determine if proper treatment was initiated. Residents that are identified during this audit will be reassessed, treatment will be started and progress will be monitored. 12/26/2016
c) All staff attended mandatory STOPANDWATCH tool training on (MONTH) 24, (YEAR)- (MONTH) 27, (YEAR). All nursing staff will be in-serviced on skin assessment and 24 hour report. 12/26/2016
d) Compliance officer will conduct a monthly audit of all residents currently on weekly skin checks to determine if proper treatments were initiated. Results of the audit will be reported at quarterly QA. 12/26/2016
e) Responsible staff: Compliance officer