Golfview Developmental Center
Facility I.D. Number: 0042614
Date of Survey: 09/15/2003
The facility shall provide all services necessary to maintain each resident in good physical health.
These services include, but are not limited to, the following:
b) Nursing services to provide immediate supervision of the health needs of each resident by a registered professional nurse of a licensed practical nurse, or the equivalent.
Residents shall be provided with nursing services, in accordance with their needs, which shall include, But are not limited to, the following: The DON shall participate in:
Periodic reevaluation of the type, extent, and quality of services and programming.
Modification of resident care plan, in terms of the residents daily needs, as needed.
AN OWNER, LICENSEE, ADMINISTRATOR, EMPLOYEE OR AGENT OF A FACILITY SHALL NOT ABUSE OR NEGLECT A RESIDENT.
These regulations were not met as evidenced by the following:
Based on observations, interviews and record reviews, the facility failed to ensure that individuals received nursing services to ensure the integrity of their skin. R15 did not receive adequate monitoring of his skin integrity which resulted in the development of a decubitus ulcer discovered at a Stage 4. R15's decubitus involved the complete right cheek of the buttock to the bone with necrotic tissue. The facility failure to have complete and consistent documentation of R14's decubitus ulcers including type, number, color, size and condition of the ulcers. R14 has multiple stage 1, 2 and 3 decubitus ulcers which have not improved or have worsened. R16 has a large red excoriation of her left abdomen with an open area which has not improved and which the facility failed to adequately document.
1) Record review on 8/25/2003 states R15 is a 62-year-old male with a diagnosis of Moderate Mental
Retardation, Depression, Hypothyroidism, Chronic Stasis Dermatitis, Peripheral Edema, Bilateral Venous Insufficiency with Cellulitis. Record review on 8/25/2003 of the Patient Transfer Form dated 7/31/2003 states R15 was transferred to a local hospital for possible Sepsis and Decubitus. Review of nursing progress notes from 7/6/2003 to 7/29/2003 does not indicate the presence of a decubitus ulcer to his right buttocks. The nursing progress notes first notation regarding an open area on R15's buttocks was documented on 7/30/2003 at 1300 (1:00 p.m.) which states "Open area at Right gluteal 3" x 2" with redness and oozing serous, area at coccyx dime size (1cm round) healing. Left Hip quarter size (2cm round healing - scrotum with 2 dime size red areas. 10:30p.m. ...Large sore on right gluteal region...R15 placed on list to be assessed in house tomorrow by Z3".
Review of Z3's Physicians Progress note dated 7/31/2003 states "asked to see pt for new skin breakdown on buttocks...Exam: skin 1. Right ankle area conts. to be open and post portion with purulent drainage. Coccyx-decub. almost healed open to area. 3. R-buttock large ulcerated decubitus ulcer with necrotic tissue covering most of buttocks. Area outside of ulcer reddened warm and hard area. 4. R-hip two opened areas ^2-3 cm in circumference. HEENT- Pt with purulent drainage from nose... A/P - Send to ER for evaluation R/O Sepsis". Interview with Z3 on 8/26/2003 states she was asked to see R15 on 7/31/2003 and observed R15 with a decubitus ulcer involving the entire right buttock cheek, the decubitus extended to the bone with yellow drainage and necrotic tissue. Z3 stated that R15's development of the decubitus was discussed with E22 (nurse) and E22 stated there was no skin breakdown when she last observed the area six days prior. Z3 states R15 has a history of low protein levels but does not know why the skin breakdown was not discovered before it became a stage 4 decubitus ulcer. Interview with E22 on 9/2/2003, states the last time she saw R15's buttock was six days prior to the discovery of the decubitus ulcer. E22 states there were no open areas on R15's cheek (buttock). E22 states on 7/30/2003, "Had not seen him for six days, I came back on 7/29/2003. I usually check all clients but did not get a chance to see him, so I put it on the log for the day nurse to check. When I came back on 7/31/2003, Z5 explained (to me) about large opening on R15's buttocks. I don't understand why staff did not report this, (the) client is showered, has a diaper (and) positioning schedule". E22 states, "R15 is showered by the 12 a.m. to 8:30 a.m. shift."
Review of photographs taken of R15's buttocks on 7/14/2003 show no indication of a decubitus ulcer on the right cheek of the buttock. Photographs taken on 7/30/2003 of R15's buttocks showed a large open area on his buttock, involving his whole right cheek. Review of R15's Decubitus Ulcer Susceptibility Predictive Criteria dated 6/1/2002 states a Total Susceptibility Score of 5 (low risk). Review of Discharge Staffing dated 8/6/2003 states "skin breakdown continued to be an issue and on 7/30/2003, R15 was noted to have a Decubitus to his left buttock and was put on the list to see Z3 the following day. E22 and Z3 both felt it was necessary to send him out to the hospital due to his Albumin and Protein Levels being off and the area looking infected. He was sent to ... Hospital on 7/31/03 and received IV antibiotics to help fight off the infection quicker." Interview with E3, Director of Nurses, on 8/19/2003, states she was first notified of the R15's decubitus ulcer on 7/30/2003 and R15 was put on the list to see Z3 on 7/31/2003 and was sent to the hospital on 7/31/2003.
Record review on 8/25/2003 states R14 is a 54-year-old male with a diagnosis of Profound Mental Retardation, Down's syndrome, Blind in Left Eye, Anemia, Mitral Valve Prolapse, Abnormal EKG. Review of Physician Order Sheet dated 7/1/2003 to 7/30/2003 states R14, on 7/10/2003 "Contact Isolation d/t (due to) exposure to roommates papular rash per T.O. (telephone order) Z3". R14 was in isolation from 7/10/2003 to 8/14/2003.
R14 was observed in his room in bed on 8/25/2003, Z5 present in the room taking photographs of R14's buttock. Surveyor observed multiple areas of excoriation, six open decubitus ulcers on upper and lower left buttock and right lower buttock. Surveyor asked Z5 how many decubitus she observed on R14's buttock and she stated three decubitus. Z5 stated R14 is incontinent of urine and stool. Interview with E3 on 8/19/2003, states R14 decubitus were acquired in the facility and he has (2) stage-1 decubitus and (3) stage-2 decubitus. E3 states R14 is ambulatory and likes to change his position. E3 states R14 requires dressing changes every three days and nursing should document the condition of the decubitus in the nursing progress notes. Review of physician's order sheet dated 7/1/2003 states "apply ... drsg to buttocks - change every 3 days and as needed and continue to clean lesion with each dressing change with ....wound cleanser". Review of nursing progress notes from 1/5/2003 to 8/20/2002 indicated inconsistent documentation of the type, number, color, size and condition of the decubitus ulcers which is illustrated by the following examples:
1/4/2003 - 6 superficial dime size area noted to right buttock.
1/29/2003 - ... dressing applied to sores x5 on buttocks
2/6/2003 - ...dressing applied
2/7/2003 - sore on upper buttock area near rectal opening is open with bleeding ...dime size.
2/8/03 - 2-1/2 inch sores noted to right and left buttock
4/13/2003 - new ...dressing applied. Buttock sores appear to be spreading again.
4/22/2003 - ... (dressing) applied to buttocks sores no bleeding.
5/7/2003 - Multiple Stage II -III Decubiti to right buttock and scrotum, dressing (changed) to all wounds. Continue to monitor.
5/14/2003 - ... (dressing) applied to buttocks to 2 areas
5/19/2003 - RX done ...(dressing) applied to b oth buttock areas. Rt buttock with one quarter-size Stage II and one dime-size Stage I. Lt. Buttock with one quarter-size stage II. All decub areas with no odor or drainage.
5/21/2003 - Buttock areas with soreness remains unchanged.
5/31/2003 - changed (dressing)... to buttocks x3 sites
6/3/2003 - ...(dressing) to buttocks changed
6/16/2003 - ... (dressing) changed x5 sites
6/21/2003 - ...(dressing) applied to buttock sores, red blotches still noted on gluteal region.
6/23, 6/27, 7/2, 7/5/2003 - ...(dressing) changed
7/13/2003 - Decubitus on buttock draining brownish red purulent fluid & odorous ...(dressings) changed to all 3 sores.
7/14/2003 - ...(dressing) changed x4 sites
7/19/2003 - dressings changed no drainage or foul odor from sores
7/27/2003 - ...(dresssing) changed no drainage
Additional nursing notes are 7/30, 8/4, 8/9, 8/15, 8/18/2003 are inconsistent in R14's current condition of his decubitus ulcers.
Physician progress note dated 10/11/2002 states "Decubitus Ulcers Looks great only 2 remaining ulcers L- buttocks closing almost resolved, R Buttocks healing about <1cm, all other areas healed". Physician progress notes dated 5/23/03 states "decub ulcers 2-stage II on buttocks". Physician progress notes dated 6/11/03 states "Decubitus Ulcer 6-stage II ulcers on buttock, varying sizes 1 cm - 3 cm.
Record review on 9/3/2003 states R16 is a 69-year-old female with a diagnosis of Profound Mental Retardation, Down's Syndrome, Syncope, Seizures. R16 is non-verbal and deaf.
R16 was observed on 9/3/2003 at approximately 1:40 p.m., R16 was observed sitting in a wheelchair in the activity room on the second floor. E22, nurse, wheeled R16 in to her room for an examination of her gastrostomy site. E22 obtained assistance from a direct care staff and lifted R16 into bed. R16's pants were wet with the edges of the wet mark drying. E22 proceeded to take off her pants and R16's diaper was saturated with urine and a thick mustard brown matter. When E22 removed R16's abdominal binder gauze wrap and a thick mustard brown matter was on the gauze wrap. E22 than took off the dressing from over the gastrostomy tube site and left lower quadrant, surveyors observed R16's with excoriation in the left lower quadrant, the skin was deep red in color, and measuring approximately 6 inch by 6 inch with a 1.5 cm open area and the area was cover with a thick mustard brown matter. Interview with E22 and E25 on 9/3/2003, states this "area was not this bad yesterday (9/2/2003) and the area has gotten worse". Review of Nursing Progress Notes from 8/19/2003 to 9/3/2003 does not identify any alteration in skin integrity for R16's left medial lower quadrant.