Health inspection·January 8, 2021

F309 - 483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices, including but not limited to the following: When Resident 1 developed open wounds on his right hand, the wounds were not consistently assessed as per the facility's P&P (policy and procedure) for wound management. * On 8/22/20, the neurosurgery consultation was ordered for a baclofen (medication to treat muscle spasm) pump. This was not obtained prior to Resident 1's need for partial right middle finger amputation and tendon lengthening in his right arm. * On 9/29/20, the peeling skin was noted on Resident 1's right middle and pinky fingers. The facility failed to ensure a care plan problem was developed to address the peeling skin and the wound was assessed according to the facility's P&P. * On 10/3/20, wounds were noted on Resident 1's right fourth and fifth knuckles. The wounds were treated with Bacitracin (antibiotic) for 13 days prior to going to the acute care hospital on 10/16/20. However, the facility did not assess the wounds during this period as per the facility's P&P. * On 10/4/20, an open wound was identified on Resident 1's right middle fingertip. From 10/4 to 10/15, the wounds were not thoroughly assessed as per the facility's P&P. * The facility did not have a P&P for nail care. Their staff were not allowed to cut the residents' nails and relied on the family members to cut a resident's nails. Resident 1 had severe right hand contractions and his fingers dug into the palm of his hand which caused a full-thickness pressure injury. These failures contributed to Resident 1's right hand wounds worsening which required the surgical intervention at the acute care hospital. Findings: Medical record review for Resident 1 was initiated on 10/24/20. Resident 1 was admitted to the facility on 8/6/20, and discharged to the acute care hospital on 8/8/20. He was readmitted on 8/18/20, and discharged to the acute care hospital on 8/26/20. He was readmitted to the facility again on 8/29/20, and discharged to the acute care hospital on 10/16/20, for evaluation of his right hand. Review of Resident 1's MDS (Minimum Data Set) dated 9/4/20, showed he was totally dependent on staff for ADL (activities of daily living) care. It also showed he had functional limitations in range of motion on the lower and upper extremities. On 10/24/20 at 0806 hours, an observation of Resident 1 was conducted with RNs (Registered Nurse) 1, 2, and the Administrator. Resident 1 was observed lying in bed with his right arm in a purple cast from the upper arm to his fingers. The ends of his right fingers were covered with a dressing. The administrator stated Resident 1 had recently returned from the acute care hospital. He was not verbally responsive to the staff speaking to him. RN 2 stated Resident 1's right fingers had been so contracted, and they could not open them and his fingers would dig into his hand. RN 1 stated two staff could not open his hand. a. Review of Resident 1's Order Detail showed the physician's order dated 8/22/20, for a neurosurgeon consultation. The order showed after discussion with the acute care hospital's neurosurgery, Resident 1 would benefit from a baclofen pump (consists of a pump and a catheter that brings the medication from the pump into the spinal fluid). Review of Resident 1's Team Conference Notes dated 8/25/20, showed attempts of getting the neurosurgery follow- up had been unsuccessful. Review of Resident 1's Case Management Notes dated 10/8/20, showed the authorization was requested from the insurance company so Resident 1 could be seen by the neurology/neurosurgery. Another note dated 10/14/20, showed the case management was still working with the patient's insurance to obtain authorization for the neurology/neurosurgery consult. On 11/13/20 at 1200 hours, an interview was conducted with the Case Manager. The Case Manager verified the above findings and stated when a resident was so tight with his muscles, a cocktail of medications was tried. The pump would constantly provide muscle relaxants so the resident's limbs could be positioned, and they could adjust the dosage of the medication remotely. On 11/19/20 at 0845 hours, an interview and concurrent medical record review was conducted with the Administrator. The Administrator stated the reason for the neurosurgery consultation for the baclofen pump was for Resident 1's toning and contractures. She stated it was hard to give enough baclofen via GT (gastrostomy tube, a small tube placed through the abdominal wall into the stomach, used to provide feeding formula and/or administer medications) to help. The Administrator stated the physician thought it might help the resident's toning, but his contractures were already bad. The Administrator stated the neurosurgery consultation had not yet been done for the baclofen pump. On 11/23/20 at 1325 hours, a telephone interview was conducted with Physician 1. Physician 1 was asked if the neurosurgery consultation and baclofen pump would have helped Resident 1. Physician 1 stated absolutely, it would have made a difference. b. Review of the facility's Wound Management P&P revised 6/20/20, showed the wound assessment includes wound history, location of wounds, wound stage, layers of wound involved, wound measurements in centimeters, color and appearance of the wound, exudate/drainage, amount and color, surrounding tissue, margins, edema, peripheral tissue indurations, and odor. Staging is only done in wounds derived from pressure. Impaired skin integrity will be addressed on the care plan when the problem is identified. All nursing staff that provides wound care will document daily the condition and appearance of the skin, integrity, and site, measurements and treatment being used. Review of Resident 1's List Patient Notes showed the following nursing entries dated: - 9/29/20, the licensed nurse changed Resident 1's handrolls and noticed red abrasions on the middle finger and pinky finger where the nail was, and the skin was peeling off and red. The nail on Resident 1's pointer (index) finger was black. His hands were contracted in a tight fist all day and the handrolls were placed to keep him from digging his nails into his palm. - 10/3/20, the skin of Resident 1's right fourth (measuring 1.0 cm by 1.0 cm) and fifth (measuring 1.0 cm by 0.5 cm) knuckles were open due to him rubbing at his tracheostomy mask. The documentation showed there was no bleeding or drainage noted. Resident 1's physician was notified and Bacitracin ointment was ordered. - 10/5/20, the licensed nurse noted Resident 1's right hand and fingers were strongly contracted and the right middle finger had an open wound at the tip. The documentation showed it was concluded that Resident 1's nail was digging into the skin. Scant blood was noted, but there was no active bleeding. The wound measured 1.5 cm by 1.0 cm. - 10/9/20, Resident 1 had the right hand bleeding. The documentation showed the skin around Resident 1's fingers were denuded with nail bed starting to come off from his fingers. The physician was made aware and gave new wound care orders. - 10/10/20, the fingers of Resident 1's right hand were digging into his palm. The skin of the palm and fingers were sweaty and denuded. - 10/11/20, Resident 1's wound on the knuckles were still open with drainage noted. - 10/11 and 10/12/20, the treatments to Resident 1's right knuckles, pinky and middle fingers were done as ordered. The documentation showed bleeding was noted to the site with increased (skin) breakdown. - 10/14/20, Resident 1's physician ordered a wound consultation due to increased (skin) breakdown. - 10/16/20, the licensed nurse spoke with Resident 1's physician and received an order to send Resident 1 out to the emergency department via 911 for further evaluation of the finger wound. Review of Resident 1's Physical Assessment showed the following entries dated: - 10/4, 10/5, and 10/6/20, Resident 1's nail on the third digit of the right hand was digging into the fingertip causing the epidermis (outer layer of the skin) to peel off. The documentation showed this could be due to the digit contractures of the right hand. The wound measured 1.5 cm by 1 cm. - 10/7, 10/8, and 10/9/20, Resident 1 had an open wound to the right third digit. On 10/9/20, his fingers were very contracted and digging into the palm of his right hand. -10/10 and 10/12/20, Resident 1 had an open wound to the right third digit, with serosanguineous drainage (wound drainage containing blood and clear yellow liquid). -10/13/20, Resident 1's right fourth and fifth knuckles, open wound, serosanguineous. It showed the right third digit was "discontinued." -10/14 and 10/15/20, the right 4th and 5th knuckles, open wound, serosanguineous. There was no note about the right middle and pinky fingers. None of these assessments showed the stages of the wounds, or odor. Not all of the assessments showed the measurements of the wounds to determine if the wounds were improving or worsening. Review of the plan of care failed to show a care plan problem was developed to address Resident 1's red abrasions on the middle and pinky fingers, nor for the peeling skin. On 10/28/20 at 1420 hours, an interview was conducted with RN 4. RN 4 stated if treatment was being done to a resident's wound, there should be a daily wound documentation so they could tell if the wound was getting better or worse. The wound documentation should describe the wound and any drainage. On 11/19/20 at 1130 hours, an interview and concurrent medical record review was conducted with RN 7. RN 7 stated she called Resident 1's physician on 10/9/20, because of his right hand. RN 7 stated denuded meant the skin was peeling off his finger, and she really could not measure it as the skin was coming off of his whole right middle finger. Resident 1's right pinky and middle fingers' nail beds skin were coming off. RN 7 stated when she called the physician, the physician was surprised at what she said as she only knew about wounds on his knuckles so far. RN 7 stated she cared for Resident 1 a week later and was the nurse who sent him out to the acute care hospital. Resident 1's hand was significantly different than the week before. It was gross. Resident 1's right middle finger was swollen and smelled bad, and that nail was almost gone. RN 7 stated when she squeezed on his right middle finger, she observed yellow pus come out. RN 7 stated she got the physician to see his hand and the physician took action. RN 7 stated the night shift told her Resident 1's finger had drainage; it was bad and something needed to happen. Review of Resident 1's Emergency Department Note - Physician dated 10/16/20, showed per staff at the facility, due to Resident 1's contractures, the wound on his fingers could not be cleaned and had been bleeding with purulent (pus) matter for the past three to four days. The documentation showed upon examination, Resident 1's right third distal digit was swollen with circumferential erythema (redness encircling the finger), purulent drainage with evidence of darkened eschar (dark necrotic/dead tissue) in the middle. The fifth digit had similar erythema and swelling to digit aspect. The physician's diagnoses were skin infection, necrotic finger, cellulitis (bacterial skin infection), and sepsis. Review of Resident 1's Orthopedic Progress Notes dated 10/20/20, showed he was admitted for concerns with the right hand contracture with full thickness pressure ulcers. Resident 1 was now status-post right tendon lengthening as well as debridement of the small finger, and long finger PIP (interphalangeal - the middle knuckle) amputation with incision and drainage and long-arm cast application on 10/19/20. On 11/19/20 at 0845 hours, an interview and concurrent medical record review was conducted with the Administrator. The Administrator stated a resident's care plan should be updated by the floor nurses for any newly discovered problems, especially if the physician was called. The Administrator stated she doubted the floor nurse updated the care plan when the resident's right middle finger was found to have an open area on 9/29/20. The Administrator stated she expected staff to update the care plan and assess the resident's wound daily which included measuring, staging, photographing the wound as well as describing any drainage in their documentation. The Administrator stated this was not done for Resident 1's right hand wounds but should have been done. The Administrator stated she saw Resident 1's hand on 10/14/20, and stated the middle finger and nail was unrecognizable. It was so swollen. The nail was hanging there. The Administrator stated they could not move Resident 1's fingers. Resident 1's pinky finger was pressing into his hand, and his middle finger was white from pressure. The nail was black. The Administrator stated there was a washcloth in Resident 1's hand but washcloths don't always work. The Administrator stated she depended on the nurses for update. She was the last one to know how bad Resident 1's hand was. The Administrator stated if she had been told, it would have been a non-issue with getting authorization from Resident 1's insurance company. The Administrator stated none of this should have happened. c. On 10/28/20 at 1515 hours, an interview was conducted with RN 5. RN 5 stated the staff would not cut any residents fingernails. They would only file the residents' nails. RN 5 stated she did not know who should cut a resident's nails and it was difficult to open Resident 1's hands. RN 5 stated she could not even see Resident 1's fingernails as his fingers were pressed into his palm when he was clenching his fist. On 11/9/20 at 1120 hours, an interview was conducted with LVN 2. LVN (Licensed Vocational Nurse) 2 stated she took care of Resident 1 for a few days prior to Resident 1 going to the acute care hospital. LVN 2 stated Resident 1's wound was actively bleeding and the right middle fingernail was lifted up at the end and pushed back into his finger. The tip of the finger was raw and the side of the finger was peeling from moisture. The skin on his palm was intact. The right pinky fingernail was also lifted up some at the end and pushed up a little into the finger. The middle fingertip was a little bit black. LVN 2 stated she was afraid of breaking Resident 1's finger when she tried to open his hand. On 11/13/20 at 0900 hours, an interview was conducted with CNA (Certified Nursing Assistant) 5. CNA 5 stated she cared for Resident 1 either late September or early October. CNA 5 stated Resident 1's right middle finger was pretty bad. CNA 5 stated something smelled as she walked into the room, and it smelled weird. It smelled like flesh and was terrible. CNA 5 stated when they tried to open Resident 1's hand, it was wrinkly like when you hold your hand under water for so long, and smelled really bad. It looked like the skin was going to come off. CNA 5 stated when she washed Resident 1's hand, she didn't know if it was skin or dirt that came off. Resident 1's skin was peeling and he was bleeding a little from his pinky finger. It looked like his middle fingernail was going to come off or already had came off. CNA 5 stated they were not supposed to cut fingernails, only file them. It would have been a two-person job to file Resident 1's nails. On 11/13/20 at 0925 hours, an interview was conducted with PT (Physical Therapist) 1. PT 1 stated she assessed Resident 1 with the orthotics representative and they were only able to move his right pointer finger a little. PT 1 stated she was unable to see Resident 1's other fingernails, but this one was long and needed to be cut down for sure. On 11/13/20 at 1230 hours, an interview was conduc