Other·November 4, 2021

T22 72311. Nursing Service – General. (a) Nursing service shall include, but not be limited to, the following: (1) Planning of patient care, which shall include at least the following: (B) Development of an individual, written patient care plan which indicates the care to be given, the objectives to be accomplished and the professional discipline responsible for each element of care. Objectives shall be measurable and time limited. (C) Reviewing, evaluating and updating of the patient care plan as necessary by the nursing staff and other professional personnel involved in the care of the patient at least quarterly, and more often if there is a change in the patient's condition. (2) Implementing of each patient’s care plan according to the methods indicated. Each patient’s care shall be based on this plan. F684 CFR § 483.25 Quality of Care Each resident must receive, and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. The facility failed to provide necessary wound care services for Resident 1 who had a right and left lower extremities venous ulceration (wound on the skin due to a pooling of blood in the veins, most often on the legs) and in accordance with current professional standard by ensuring: 1. Resident 1 received appropriate wound treatment on right and left lower extremities (lower legs) venous ulceration on 8/5/21 to 8/8/21 total of 4 days and notify the physician when the wound treatment was completed on 8/5/21 to 8/8/21 for further evaluation and wound treatment order. 2. The Treatment Nurse conduct weekly wound assessment to Resident 1’s right and left lower extremities and document in the resident's weekly skin progress report. 3. Resident 1’s care plan for right and lower extremities venous stasis ulcer was updated and implemented to ensure appropriate treatment order provided. These deficient practices resulted in Resident 1's left lower extremity (LLE, left lower leg) and right lower extremity (RLE, right lower leg) venous ulceration to develop in three new sites. On 8/9/21 resident was transferred to General Acute Care Hospital (GACH) due to shortness of breath and found to have maggots (baby flies or the larval stage of a fly) to the resident’s lower extremities venous stasis ulcer during assessment. Findings: An unannounced complaint visit was conducted at the facility on 8/20/21 to investigation an allegation regarding quality of care. A review of Resident 1's Admission Record indicated the resident was a 72 year old female who was admitted to the facility on 4/1/2021, with a diagnosis that included Chronic Venous Hypertension (a condition in which blood pressure rises inside your leg veins) with ulcer (a break in skin or mucous membrane) of bilateral lower extremity (part of the body that includes the leg, ankle, and foot). A review of Resident 1's Wound Risk Assessment, dated 4/1/2021, indicated Resident 1 score was 6, indicating the resident was at moderate risk for skin breakdown. A review of the Resident 1's wound progress report dated 4/2/21 indicated the resident had the following wounds: Left lower extremity venous ulceration 16X16 centimeter (cm), 0.2 cm depth with yellow slough (dead tissue, usually cream or yellow). Right lower extremity venous ulceration 7.5x8.0 cm, 0.2 cm depth Left heel venous ulceration 3x3 cm, 0.2 cm depth Left dorsal foot venous ulceration 2x2 cm, 0.2 cm depth A review of Resident 1's Wound Management Care Plan, dated 4/2/2021, indicated the care plan goal was to keep the resident's skin ulcers clean, prevent decline and be free from signs and symptoms of complications daily. One of the approached interventions indicated was to administer treatment/s as ordered by the physician, and to keep physician aware of the progress and response to the treatment plan. A review of Resident 1's History and Physical (H&P) form, dated 4/12/2021, indicated Resident 1 did not have the capacity to understand and make decisions. H& P indicated Resident 1's diagnosis included bilateral lower extremities cellulitis (a skin infection that causes redness and pain). A review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 7/13/2021, indicated Resident 1's cognition (perception, thought, memory, and ways of processing and structuring information) was moderately impaired and required extensive assistance from the staff for bed mobility, transfer, dressing, toilet use, and personal hygiene. A review of Resident's 1 Order Summary Report, indicated for Resident 1 to receive the following treatments: 1. Order dated as 7/5/21 to apply Silvasorb gel (medication gel use in the management of wounds such as stasis ulcer) to left lower extremity (lower leg) every day shift for peripheral vascular disease (PVD, a blood circulation disorder) for 30 days. Cleanse site with normal saline (NS, normal salt solution), pat dry, apply Silvasorb, cover with dry dressing, and may wrap with kerlix (large roll dressing). 2. Order dated as 7/5/21 apply Silvasorb gel to right lower extremity every day shift for PVD for 30 days. Cleanse site with NS, pat dry, apply Silvasorb, cover with dry dressing, and may wrap with kerlix. 3. Order dated as 7/5/21 apply Silvasorb gel to left dorsal foot every day shift for PVD for 30 days. Cleanse with NS, pat dry, apply Silvasorb, cover with dry dressing, and may wrap with kerlix. 4. Order dated as 7/5/21 apply Silvasorb gel to left heel every day shift for PVD for 30 days. Cleanse with NS, pat dry, apply Silvasorb, cover with dry dressing, and may wrap with kerlix. A review of Resident 1's wound care consultant lower extremity wound assessment, dated 7/23/2021, indicated Resident 1 had a debridement (a surgical removal of dead or infected skin tissue to help a wound heal) procedure on her left lower leg, left heel, right lower leg, left dorsal foot, right shin and left shin venous stasis ulcer wounds. A review of Resident1's Order Summary Report indicated new order for the following new wound site: 1.Order dated as 7/23/21 apply Silvasorb gel on skin to left shin every day shift for venous stasis until 8/23/21. Cleanse site with NS, pat dry, apply Silvasorb gel, cover with dry dressing, wrap with kerlix daily for 30 days. 2.Order dated as 7/23/21 apply Silvasorb gel to right lateral ankle every day shift for venous stasis until 8/23/21. Cleanse site with NS, pat dry, apply Silvasorb gel, cover with dry dressing, wrap with kerlix daily for 30 days. 3. Order dated as 7/23/21apply Silvasorb gel to right shin every day shift for venous stasis until 8/23/21. Cleanse site with NS, pat dry, apply Silvasorb gel, cover with dry dressing, wrap with kerlix daily for 30 days. A review of Resident 1's Treatment Administration Record for 8/2021, indicated an x mark with no initial by the treatment nurse for 4 days from 8/5/21 to 8/8/21: 1.Left lower extremity venous ulceration 2.Right lower extremity venous ulceration 3.Left heel venous ulceration 4.Left dorsal foot venous ulceration A review of Resident 1's wound care consultant lower extremity wound assessment, dated 7/30/21, indicated Resident 1 refused the examination of her wounds and wound treatment. Wound care consultant progress notes indicated would reattempt the examination on the next visit. A review of Resident 1's Change of Condition (COC) form, dated 8/9/2021 and timed at 2:33AM, indicated that Resident 1 had difficulty breathing and had episode of desaturation (low oxygen in the blood, normal range is between 95% to 100%) ranging from 83% to 89%. Primary physician was notified, and Resident 1 was transferred to GACH (General Acute Care Hospital). A review of Resident 1's GACH Wound Records, dated 8/9/2021 and timed at 12:27PM, indicated Resident 1 has stasis ulcer with full thickness tissue loss with cellulitis on left and right lower legs. WCRN 1 removed the old xeroform gauze (a wound dressing), black in color and the wound surrounding the skin on left and right lower legs has maggots. A review of Resident 1's GACH Microbiology report, dated 8/9/2021, regarding wound culture with gram stain (a laboratory test to help determine whether a wound is infected and to identify the bacteria causing the infection), indicated: 1. On left leg Resident 1's wounds had multiple species present and is positive for Methicillin-Resistant Staphylococcus aureus (MRSA, a type of bacteria that is resistant to several antibiotics [medicines that help stop infections caused by bacteria]). 2. On right leg Resident 1's wounds had multiple species present and is positive for Alcaligenes faecalis (a bacterial infection that is difficult to treat due to its increased resistance to several antibiotics). On 8/20/2021 at 11:04 AM, during a telephone interview, GACH SW 1 stated WCRN 1 called and reported to her that during her assessment and treatment of Resident 1's wound on the telemetry unit, WCRN 1 found the old dressing black in color on Resident 1's left and right lower leg wound and had maggots inside. On 8/20/2021 at 1:42 PM, during an interview, Treatment Nurse 1 stated Resident 1 had venous ulcers on both her lower extremities. Treatment Nurse 1 described the wound as reddish with small amount of drainage. On 8/20/2021 at 2:02 PM, during an interview, CNA 1 stated Resident 1 would yell and scream when attempting to provide nursing care and has been refusing care and treatment. CNA 1 stated Resident 1 had wounds on both her legs and had not seen the wound. On 8/20/2021 at 2:10 PM, during an interview, LVN 1 stated Resident 1 would not want to be touch and would scream and yelled at the top of her lungs when encouraged with the care. LVN 1 stated they would wait until Resident 1 in a good mood to be able to administer the medication and provide nursing care, bathing, and wound treatment. On 8/20/2021 at 2:45 PM, during an interview, the Director of Nursing (DON) stated if Resident 1 refused treatment, the treatment nurses would go back later the same day to convince the resident for wound care treatment. DON stated if the resident refused wound care treatment, the nurses must document the resident refusal in the nursing progress notes. On 8/20/2021 at 3:03 PM, during a concurrent interview and record review, Treatment Nurse 2 stated the x mark on the resident's TAR dated 8/5/21 to 8/8/21 indicated the wound treatment was not provided for wounds on LLE, RLE, left dorsal foot and left heel. Treatment Nurse 2 stated an "x" mark on the TAR indicates treatment was not done. Treatment Nurse 2 stated she was newly employed and was learning and familiarizing with the facility's processes. On 8/26/2021 at 3:42 PM, during a subsequent interview, Treatment Nurse 2 stated the treatment orders for wound sites on LLE, RLE, left dorsal foot and left heel has completed because the order was for 30 days due on 8/5/21. Treatment Nurse 2 stated that there should be a continuation of that treatment orders and would have to reflect on the updated TAR for the month of August 2021. On 9/10/2021 at 4:12 PM, during a phone interview, wound care registered nurse (WCRN 1) on GACH stated on 8/9/21 during Resident 1's admission wound assessment, the resident was observed with an old dressing, when she removed Resident 1's old top dressing on both lower legs, the xeroform bandage that covered the wound was black in color and had maggots surrounding the wounds on the skin. On 9/14/2021 at 11:55 AM, during an interview and record review, the DON stated Resident 1 wound treatment on LLE, RLE, left dorsal foot and left heel stasis ulcer were not renewed after the treatment order ended on 8/5/2021 and the physician was not notified on the resident wound progress if the wound care and treatment plan has to continue or has to change the wound treatment. DON stated the resident medical record did not have documentation on Resident 1's wound progress on LLE, RLE, left dorsal foot and left heel. On 9/30/2021 at 2:05 PM, during a telephone interview, DON stated the facility would assess wounds on admission, when providing wound care treatment. DON stated the Treatment Nurse must document the wound progress weekly on the skin progress report form and update the care plan. DON could not provide documented record of Resident 1's weekly skin progress report from 6/2021 to 8/2021. On 10/5/2021 at 9:36 AM, during a telephone interview, Wound Care Specialist (healthcare professionals who have received specialized training to treat and care for every kind of wound, whether they are severe or chronic in nature). Medical Doctor 1 (MD 1) stated normally he go visit the facility and do his rounds on the residents at least once a week. MD 1 stated he had found Resident 1's kerlix dressing to be soiled and dirty a few times and the nurses told him it was because Resident 1 refused treatment. MD 1 stated he observed many times Resident 1's dressing to be clean and dry and had not seen xeroform gauze to be color black. MD 1 stated it was not normal if xeroform gauze was black in color and it would indicate the dressing was soiled, and the wound had moderate amount of serosanguineous (contains blood and liquid part of the blood[serum]) drainage. MD 1 stated he saw a few times Resident 1's wound had heavy drainage and if wound treatment was not done even for a day, drainage will accumulate, and it will stall (stop or delay) the healing process of the wound. According to an article published by National Institute of Health, https://pubmed.ncbi.nlm.nih.gov/17199831/, indicated that infection plays various roles in the etiology, healing, operative repair, and complications of venous ulcers. Necrotic tissue is laden with bacteria while devitalized tissue impairs the body's ability to fight infection and serves as a pabulum for bacterial growth. High levels of bacteria of beta hemolytic streptococci impede the various wound-healing processes and have been demonstrated to impede spontaneous healing and surgical closure of venous ulcers. The facility failed to provide necessary wound care services for Resident 1 who had a right and left lower extremities venous ulceration (wound on the skin due to a pooling of blood in the veins, most often on the legs) and in accordance with current professional nursing standard by ensuring: 1. Resident 1 received appropriate wound treatment on right and left lower extremities (lower legs) venous ulceration on 8/5/21 to 8/8/21 total of 4 days, and notify the physician when the wound treatment was completed on 8/5/21 to 8/8/21 for further evaluation and wound treatment order. 2. The Treatment Nurse conduct weekly wound assessment to Resident 1’s right and left lower extremities and document in the resident's weekly skin progress report. 3. Resident 1’s care plan for right and lower extremities venous stasis ulcer was updated and implemented to ensure appropriate treatment order provided. These deficient practices resulted in Resident 1's left lower extremity (LLE, left lower leg) and right lower extremity (RLE, right lower leg) venous ulceration to develop in three new sites. On 8/9/21 resident was transferred to General Acute Care Hospital (GACH) due to shortness of breath and found to have maggots (baby flies or the larval stage of a fly) to the resident’s lower extremities venous stasis ulcer during assessment. These violations, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of patients or residents.