Rosewood Rehabilitation and Nursing Center

Deficiency Details, Complaint Survey, March 20, 2013

PFI: 3920
Regional Office: Capital District Regional Office

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F314 483.25(c): PROPER TREATMENT TO PREVENT/HEAL PRESSURE SORES

Scope: Isolated

Severity: Actual Harm

Corrected Date: May 7, 2013

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.

Citation date: March 20, 2013

Based on record review, resident observation and staff interview during a complaint investigation (NY00126469) the facility did not 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. Specifically, one resident (# 1) of two residents reviewed was found to have developed black, unstageable areas to his heels, right heel 5 centimeters (cm) by 3.5 cm and the left heel 5 cm by 3 cm. Additionally, this resident was not turned and positioned by staff members, and had no preventive devices to protect his lower extremities while in bed, which he could not move independently. This resulted in actual harm that is not immediate jeopardy. This is evidenced by:

The policy and procedure (P&P) entitled Pressure Ulcer Risk Assessment, dated as revised 12/2010 documented all residents will be assessed for risk of pressure ulcer development utilizing the Braden Scale.

The P&P entitled Pressure Ulcer Prevention, dated as revised 9/2010 documented that residents do not develop pressure ulcers, unless clinically unavoidable. A resident who had an ulcer receives care and services to heal the ulcer and prevent additional ulcers. Policy included: residents skin will be checked by the CNA daily using the daily skin integrity check form and at least weekly by the nurse on bath days. Risk factors included: immobility or decreased immobility, nutritional problems, and impaired mental state.

The P&P entitled Prevention of Heel Ulcers for Special Groups, dated as revised 05/08 documented it is the policy to have a plan in place for prevention of heel ulcers on special groups of residents that are at risk for such issues. Purpose included: to identify special groups who are at high risk for development of heel ulcers. Preparation included, residents with the following medical conditions are to be considered at high risk for heel ulcer development, these included: residents unable to reposition their own lower extremities. Heels are to be inspected with am and pm care for the following: redness, pain, bogginess, and discoloration.

The P&P entitled Turning Schedule, dated as revised 9/2008 documented it is the policy of the facility that any resident identified as high risk for skin breakdown will be placed on a Turning Schedule. Procedure included: identified residents will be turned side-to-side while in bed every two hours, and the shift charge nurse will be responsible for assuring compliance.

The P&P entitled Pressure Ulcer Protocol, dated as revised 10/2010 documented all residents will be assessed for pressure ulcers on admission, re-admission, and an ongoing basis. Residents will be placed on the pressure ulcer protocol upon identification of a pressure area. Procedures documented includes: as soon as wound or skin area is identified a discovery form will be filled out, copies of the discovery form are to be sent to the members of the skin team, a pressure ulcer tracking sheet is to be initiated, an appropriate treatment will be selected, additional interventions shall be instituted at this time, resident will be seen weekly by skin team, and weekly a skin team meeting will be held with all members of the team.

The Job Description and Duties Guide for Certified Nurse Aides (CNA) documented responsibilities: utilizes nursing assistant care sheets as a guide for the delivery of care, check skin for changes and complete shower sheet, provides basic skin care, positions residents in bed/chair.

Resident # 1:

The Resident was admitted to the facility on 2/7/11 with diagnosis of cellulitis of left foot and left lower extremity with left foot fracture, dementia and history of decubitus ulcer. Resident has long and short term memory problems, is severely impaired in his decision making, and has moderate difficulty with hearing according to the Minimum Data Set (MDS), dated 12/14/12.

The Wound Assessment/Notification Form dated 2/5/13 documented Resident had unstageable, suspected deep tissue injury (SDTI) to his bilateral heels, necrotic/eschar.

The nurse notes dated 2/5/13 at 4:00 pm documented that CNA notified nurse that resident had two blackened heels. Bilaterally left heel 5 centimeters (cm) x 3 cm, right heel 4 cm x 3.5 cm. Physician saw areas and orders received.

The Incident report dated 2/5/13 documented Resident noted to have unstageable black areas on both heels. Documented foot rest discontinued, waffle boots started, heels up cushion started, and skin prep every shift.

The investigation summary signed by the Director of Nursing (DON) on 2/12/13 documented that disciplinary action was taken with the CNA who did not remove the Resident's socks when she performed the Resident's bed bath the evening prior to the discovery of the wounds. CNA reported the Resident is very combative with care and does not like his legs or feet touched.
The investigation summary documented the Licensed Practical Nurse (LPN) who was responsible to perform a skin check stated he did not do a skin check because the resident received a bed bath. LPN received a disciplinary action.

The Wound Care Specialist Evaluation, dated 2/6/13, and signed by the Wound Physician documented 95 year old male patient has an unstageable DTI (deep tissue injury) of the heel of unknown days of duration. The right heel is documented as 3 cm x 5 cm unstageable DTI. The left heel is documented as 3 cm x 5 cm unstageable DTI. Dry protective dressing and skin prep, once daily was ordered for both heels.
The Venous Doppler ( ultrasound to examine the blood flow in the major \i arteries and veins) report of the bilateral lower extremities, that was performed on 2/13/13 documented no deep venous thrombosis is identified.

The Arterial Doppler report of the bilateral lower extremities, that was performed on 2/13/13 documented no arterial occlusions are identified.

The Physician orders dated 1/29/13 documented moisturize both feet with Aquaphor daily with care, CNAs may apply.

The Diagnostic Summary Sheet dated 1/26/13 documented the Resident had the following diagnosis: failure to thrive, severe weakness, frequent falling, left foot fracture, left foot and leg cellulitis, osteoarthritis and history of decubitus ulcer.

The Braden Scale for Pressure Sore Risk, Part 2 dated 11/4/12 documented if any of the below are checked, resident is high risk for skin breakdown. The following were checked: bed mobility requires extensive to total assistance, transfer requires extensive to total assistance, and incontinence.

The Comprehensive Care Plan (CCP) entitled Skin Impairment, dated 11/4/12 documented Potential problem, evidenced by rash, and related to impaired immobility and incontinence. Interventions included: note skin every shift and notify physician of any redness or breakdown, turn and position (T&P) every two hours while in bed, pressure reducing mattress, offload heels on pillows when in bed.

The CCP entitled Activity Daily Living (ADL) Function Care Plan, dated 1/22/13 documented problem of decreased strength and cognitive deficits. Adaptive devices include multi-podus boots when out of bed. Intervention included; bed mobility requires extensive assistance.

The Rehab Communication/CNA Care Care (a CNA guide to physical assistance and devices required in caring for the resident), dated 1/11/13 documented non-ambulatory status, geri chair with foam cushion, alarm in bed, mats on floor, velcro alarm seatbelt in chair, assistance of one staff member with bed mobility. There is no documentation in regards to instructions or devices for the lower extremities or a turn and position plan.

The Resident Daily Routine Card (a CNA guide for assistance needed with ADL care), dated 1/17/13 documented under skin care to moisturize feet daily, shower on Monday, dress upper and lower body. Special instructions included: elevate legs when out of bed. There is no documentation in regards to instructions for the lower extremities when in bed or a turn and position plan.

The Resident Daily Routine Card dated 2/19/13 documented additional interventions from the previous card: off load heels at all times, blue multi-podus boots, heels up cushion. There is no documentation in regards to instructions for the lower extremities when in bed or a turn and position plan.

On 2/20/13 at 9:30 am Resident was observed lying in his bed, positioned on his back with his legs extended straight and a heels up cushion under his ankles and lower legs. Observation of Nurse Manager (NM) measuring the areas to the Resident's heels revealed the right heel had a 3 cm x 5 cm black area which appeared to be hard and dry. Resident's left heel had a 3 cm x 3 cm black area which appeared to be hard and dry.

During an interview on 2/20/13 at 9:45 am, NM stated every day the Resident's received a daily wash-up which includes their face, hand, buttocks and peri area. Residents receive a full bath or shower weekly. NM does expect the CNAs to look at the whole body every day.

During an interview on 2/20/13 at 10:15 am, LPN # 1 stated the areas were black, hard and dry when they were first discovered and there was some cracking around the edges. LPN stated that the CNAs should be looking at the entire body of the residents, every day.

During an interview on 2/20/13 at 11:30 am, NM stated the Resident's feet should be moisturized daily by the CNA who should be looking at the feet as well. NM did state that if the CNAs were moisturizing the feet they would have felt those areas on both heels. Stated that the nurses on the units were responsible to monitor that the care is getting done. NM further stated that the dopplers were ordered following the discovery of the areas and there are no circulatory issues with the Resident's legs. NM stated that there were no issues with Resident # 1's appetite or fluid intake. Stated he should be turned and positioned every two hours when in bed, that he only has independent movement of his upper extremities. NM stated that the staff failed to look at his heels daily.

During an interview on 2/20/13 at 11:45 am, CNA # 1 stated she did moisturize the resident's feet. Stated that when staffing was good they would have the time to actually look at the residents feet, but when there was less staff they would lotion without looking. CNA stated that Resident # 1 does not move on his own, he can move his arms but cannot turn or move his legs. He lays on his back whenever in bed.

During an interview on 2/20/13 at 1:00 pm, Physical Therapy Aide (PTA) stated the multi-podus boots are to be worn at all times. Resident was presently on a PT program to monitor his comfort in the Barco Chair. PTA stated the Resident is unable to move himself in the bed and should be repositioned every two hours.

During an interview on 2/20/13 at 2:30 pm, DON stated staffing was improving, that the facility had hired new CNAs and LPNs. DON stated she did not know why the Braden Scale assessment was only done once, but they should be done on a quarterly basis. She stated that weekly team meetings were not done as documented in the P&P for Pressure Ulcer Protocol, and she is not sure why this was not done. Stated that someone definitely did not do what should have been done on this man.

During an interview on 2/20/13 at 3:00 pm, LPN # 2 stated Resident # 1 should be turned and positioned every two hours because he does not move himself. LPN stated that Resident # 1 gets a weekly shower and his skin is assessed by a nurse. LPN stated he worked the evening prior to the discovery of the heel areas. He stated that because the Resident had a bed bath, he did not know he had to do a skin check. LPN stated he did not think the Resident was getting turned and positioned.

During an interview on 2/20/13 at 3:15 pm, CNA # 2 stated Resident # 1 cannot move himself in the bed, he can use his arms and can be combative, and will hit and pinch. States it takes two staff members to turn him and he is only turned for care. Stated he does not spend a lot of time in bed on evening (3:00 pm to 11:00 pm) shift, but when he is in bed it is always on his back, with his heels on the bed. CNA did give a bed bath the evening prior to the discovery of his heel areas, instead of a shower and told the nurse. The nurse never came in to do a skin check. Resident does not like to have his privates or feet touched so she did not take his socks off during the bed bath.

During an interview on 2/21/13 at 8:20 am, CNA # 3 stated on the night (11:00 pm to 7:00 am) shift they turn and position all residents every two hours. Stated Resident # 1 can move his upper extremities and cannot move his legs. Stated the Resident only gets turned when the Resident allows and even then he will not allow a pillow behind him. Stated prior to the heel areas being discovered there were no interventions in place to prevent skin breakdown. Resident spent most time on his back.

During an interview on 2/21/13 at 9:45 am, CNA # 4, stated the areas were noted on his heels when changing his socks and reported to the nurse. CNA had Resident the day before and took his socks off then, stated did not notice the areas then. CNA stated the time varied when the Resident got up in the morning and he was not repositioned before getting up. Resident was unable to reposition himself. CNA never saw Resident # 1 positioned on his side.

10 NYCRR 415.12(c)(2)

Citation date: April 16, 2013


Based on record review and staff interview, it was determined during a post-survey revisit that the facility did not ensure a resident who enters the facility without pressure sores did not develop pressure sores in 1 (#2) of 2 residents reviewed. Specifically, the facility did not complete a thorough assessment of a pressure sore. This resulted in no actual harm but had the potential for more than minimal harm that is not immediate jeopardy. This is evidenced by the following:
Resident # 2
The resident was admitted to facility on 3/29/13 with diagnoses of end stage renal disease, atrial fibrillation, and chronic obstructive pulmonary disease. Minimum Data Set (MDS) information dated 4/5/2013 assessed the resident with severe cognitive impairment, Brief Interview for Mental Status score of 3 and is able to understand and be understood. The resident was assessed with no pressure ulcers.
Nursing notes dated 4/12/13 documented at 6:30 pm (1830) that it was reported to the family that the resident has two small areas in her buttocks measuring 2 centimeters (cm) by 1 cm and 1 cm by 1 cm. No other nursing notes were available documenting the pressure ulcers.
The 24 hour nursing report dated 4/12/13 documented on the 7:00 am to 3:00 pm shift the resident needs Calmoseptine applied to buttocks surrounding duoderm every shift. The 3:00 pm to 11:00 pm shift documented the resident has 2 new areas open measuring 2 cm by 1 cm and 1 cm by 1 cm.
The Comprehensive Care Plan (CCP) for skin impairment dated 4/1/13 documented under problem an actual excoriated area related to incontinence. The goal/time frame documented the resident will not develop a pressure area with a time frame of 90 days. The outcome section documented on 4/1/13 an excoriated rectal area was noted, the physician was notified by the doctor book, and barrier cream was applied. No open areas were documented as having been discovered on 4/12/13.
The initial nutrition risk assessment dated 4/3/13 documented the resident had a Stage 2 pressure ulcer to the left gluteal area noted while in the hospital and an unstageable pressure ulcer to the right great toe. No further documentation involving pressure ulcers were available in dietary notes.
The resident physical assessment form dated 3/29/13 documented no areas of breakdown or pressure ulcers in the buttocks or gluteal folds area.
The Policy and Procedure (P and P) for Pressure Ulcer Protocol revised 10/2010 documented that it is the policy of the facility that all residents will be assessed for pressure ulcers on admission and an ongoing basis. The P and P documents under procedure that as soon as a wound is identified a discovery form is filled out completely. The discovery form may be initiated by a Licensed Practical Nurse, but must be completed by a Registered Nurse. The P and P documented that copies of the discovery form are then sent to the members of the skin team including dietary, physical therapy, nurse practitioner, unit manager, and a representative from nursing administration. The P and P further documents a pressure ulcer tracking sheet is to be initiated at the same time the discovery team is completed. The Nurse Manager and/or Registered Nurse designee (i.e. supervisor on the shifts) will assess the pressure area and document findings on the Pressure Ulcer Tracking Sheet.
No Pressure Ulcer Tracking Sheet could be found documenting a full assessment of the pressure ulcers to the buttocks areas.
During an interview on 4/16/13 at 10:00 am the Certified Nursing Assistant (CNA) stated the CNA's will check skin condition daily and will notify the nurse of the condition of the skin. The CNA stated she does not document the condition of the skin because the nurse does that.
During an interview on 4/16/13 at 10:25 am the Dietary Technician (DT)stated she could not find any document that reported the formation of the pressure ulcer and likely was not notified. The DT stated that she is notified promptly by receipt of copy of the Wound Assessment/ Notification sheet of the development of a pressure ulcer.
During an interview on 4/16/13 at 10:35 am the Director of Nursing (DON) stated a Registered Nurse is responsible for fully assessing a newly discovered pressure ulcer, initiating the discovery form, and initiating a Pressure Ulcer Tracking sheet. The DON stated the form titled Wound Assessment/Notification Form is the form used a the discovery form. The DON stated she could not find the discovery form and Pressure Ulcer Tracking sheet so they were probably not completed. The DON stated the documentation of the pressure ulcer to the buttocks areas involving an assessment was incomplete as it did not contain a description of the wound. The DON stated facility nurses were inserviced on the process for identification, and beginning treatment of pressure ulcers but apparently did not follow the process in this case. The DON stated there has multiple turnovers in nursing so the facility is constantly training new people to the process.
epn 10 NYCRR 415.12(c)(1)