Clearbrook - Wright Home Facility I.D. Number:0044297 Date of Survey: 06/10/2003 Complaint Investigation "A" VIOLATION(S): All employees, except student interns, shall attend in-service training programs pertaining to their assigned duties at least annually. These in-service training programs shall include the facility’s policies, skill training and ongoing education to enable all personnel to perform their duties effectively. The in-service training sessions regarding personal care, nursing and restorative services shall include information on the prevention and treatment of decubitus ulcers. In-service training concerning dietary services shall include information on the effects of diet in treatment of various diseases or medical conditions and the importance of laboratory test results in determining therapeutic diets. Written records of program content for each session and of personnel attending each session shall be kept. During inspections of the facility, the Department may require developmental disabilities aides to demonstrate competency in the principles, techniques, and procedures covered by the developmental disabilities aide training program curriculum described in the rules governing training programs for developmental disabilities aides (see 77 Ill.Adm.Code 395.310), when possible problems in the care provided by developmental disabilities aides or other evidences of inadequate training are observed. Failure to demonstrate competency of the principles, techniques and procedures shall result in the provision of in-service training to the individual by the facility. The in-service training shall address the developmental disabilities aide training principles and techniques relative to the procedures in which the developmental disabilities aides are found to be deficient during inspection (see 77 Ill.Adm.Code 395). 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: Nursing services to provide immediate supervision of the health needs of each resident by a registered professional nurse or a licensed practical nurse or the equivalent. Direct care personnel shall be trained in, but are not limited to, the following: Basic skills required to meet the health needs and problem of the residents. AN OWNER, LICENSEE, ADMINISTRATOR, EMPLOYEE OR AGENT OF A FACILITY SHALL NOT ABUSE OR NEGLECT A RESIDENT. (Section 2-107 of the Act) These Regulations are not met as evidenced by: Based on observation, interview, and record verification, the facility failed to ensure that nursing services were provided to preserve the skin integrity of one client (R1) who sustained a Stage IV pressure sore behind his left knee on 05/24/03. Findings include: R1, per his face sheet, is a 48-year-old male whose diagnoses includes Profound Mental Retardation and Spastic Quadri paresis. On 05/30/03, at 11:55a.m., surveyor asked E3 (Nurse Coordinator) for clients who currently have pressure sores in the facility. E3 stated, "R2 has a left outer ankle Stage II pressure sore that was acquired in the hospital, and R1 has a facility-acquired Stage IV pressure sore behind his left knee." E3 added, "The facility noted it on 5/24/03, and it was already a Stage IV then." On 5/30/03, at 1:10p.m., R1 was observed at his day-training site. E3 was changing R1's dressing. R1's pressure sore was noted to be about 3.5 cm. in diameter and about 2 cm. in depth. His tendon is clearly exposed. Review of R1's chart showed that R1 came home from a hospital admission on 03/14/03, with diagnoses of MRSA (Methicillin Resistant Staphylococcus Aureus) in the sputum and C-Diff (Clostridium Difficile) in his stool. R1 was placed in isolation until he received an order to be off of isolation on 05/23/03. During this time period, R1 would be home by himself most weekday mornings while the rest of the clients in the facility go to their day-training site. E14 (AM Supervisor) stated on 06/03/03, at 12:30p.m., "For the most part it was only R1 at home. He was one-on-one with me." E14 added, "R1 was on isolation for about a couple of months. Sometimes I would give him a bed bath during the morning to wash him up while he was on isolation, to spend time with him, and do his Passive Range of Motion (PROM). It is the PM shift's responsibility to give R1 his complete bed bath. When he got back from the hospital, R1 lost a lot of weight. He would keep his knees together. I asked the nurse--probably E3--if it was okay to put the heel bow protector on his knees to keep the bones from rubbing together. I was told it was okay, and I only put it on one knee--I think it was his left knee." Surveyor then asked E14 if the back of the left knee was looked at when she gave R1 his bed bath. E14 stated, "I would pull the heel bow protector down to put lotion on the knee. I kept checking on the knee area but not the back of the knee". E3 was re-interviewed on 06/05/03, at 10:10a.m. E3 stated, "I truly don't remember E14 asking me to put a heel bow protector on R1. I'm positive that I didn't give her an order to put the heel bow protector on R1". E4 (nurse) was interviewed via telephone on 06/03/03, at 12:55p.m. E4 stated, "I noticed the heel bow protector always on R1. E14 usually tells me that she gave R1 his bed bath during the AM shift". E6 (nurse) was interviewed on 06/03/03 at 3:10p.m. E6 also stated, "I haven't seen the heel bow protector removed from R1's knee. Every time I do treatment and feedings in his room, the heel bow protector is there. E14 usually tells me that she did a complete bed bath on R1." E6 added, "It should have been removed during the bathing process." E7 (Habilitation Aide) was interviewed via telephone on 06/03/03, at 11:10a.m., E7 stated, "R1 was wearing his heel bow protector on the left knee. When I gave him a bath, I would lower it below the knee; but I won't take it off completely because E14 always tells me that R1 had a complete bed bath during the morning shift." E5, E12, E13, and E17 were interviewed on 06/03/03. All four habilitation aides stated that at some point they gave R1 a bed bath. They all noted R1 wearing the heel bow protector on his left knee. All four staff stated they did not remove the heel bow protector during the bathing process. E11 (habilitation aide) was interviewed on 06/03/03, at 2:36p.m., E11 stated, "I worked with R1 on 05/22/03, and he was wearing the heel bow protector on his left knee. When I lowered it, R1 was flinching and very shaky. I noticed redness and slight breakage of the skin on his left knee. I thought his skin was tender on his knee because of the redness, but I didn't look behind his knee". Surveyor asked if E11 saw the backside of the heel bow protector. E11 stated, "I didn't see the back side of the heel bow protector. There had to be some drainage there as bad as his wound is. But if you just lowered the heel bow protector down his knee, you won't see the back side of it". Z3 (agency aide) was interviewed on 05/30/03, at 2:46p.m., Z3 stated, "When I took it off (heel bow protector) on 05/24/03, it smelled horrible. It was stained in the back with dried blood. R1 was bleeding. I looked at the back of his left leg, and I couldn't believe what I saw." Z1 (facility physician) was interviewed on 05/30/03, via telephone at 2:25p.m., Z1 stated, "R1's pressure sore probably started about a month ago." Z1 evaluated R1's pressure sore on 05/27/03. Z1 stated in his progress notes under physical examination, "2 cm Grade IV left popliteal ulcer with exposed tendon. No active drainage." Under Z1's plan it stated, "Wound nurse to evaluate". On 05/24/03, Z1 was paged by E3 and was informed of R1's wound. Z1 ordered "wet to dry saline dressing twice a day until seen by the wound care nurse". On 05/28/03, Z2 (wound care specialist nurse) evaluated R1 in the hospital's out-patient wound care clinic. Z2's progress notes stated, "Patient with heel bow left on left knee area for extended period of time. Patient now with a Stage IV pressure sore with white tendon exposed. Wound = 3 x 3 x 1.2 cm with 'hole' = 2.8 x 2 x 1.2 cm. Discussed with care giver that wound cannot get dry. Will use a special dressing 1-2 times per day. Will see patient in two weeks". R1 is scheduled to be seen by Z2 for follow- up on 06/11/03. On 06/03/03, at 10:35a.m., Z2 was interviewed via telephone. Z2 stated, "I was told a heel bow protector was left on his left knee. However, it should have been looked at closely. They (the facility) could have caught it sooner and addressed it earlier before it became a Stage IV ulcer." Z2 asked surveyor about the facility's staffing ratio. Surveyor informed Z2 that since R1 was on isolation during the period of March 14, 2003, until May 23, 2003, R1 more or less had a one-on-one staff during most weekday mornings. Z2 stated, "It blows my mind that they did not notice the ulcer if R1 was more or less on one-on-one during weekday mornings for about 2 months. If they were doing Passive Range of Motion (PROM), they couldn't have missed it". Z2 was asked if R1 needs surgery to address this pressure sore. Z2 stated, "R1 does not need surgery at this time. If the facility changes the dressing regularly and will not let the pressure sore get dry, then the pressure sore will hopefully be healed in 1-2 months". E3 was re-interviewed on 06/5/03, at 10:10a.m. via telephone. E3 stated, "The facility does not have a written protocol on how to treat pressure sores. We (the nurses) will call the physician once an individual has a pressure sore to get an order for treatment. The facility didn't have any pressure sores until R2 came home from the hospital, and currently we have R1". E3 further added, "For those clients identified as high-risk individuals to develop pressure sores, we had an informal every-two- hours turning schedule book that the nurse signs off per shift. It was not signed off regularly. It does not include specific times and specific positions the clients are on. We do have a standing order for cream to be applied on any area noted to have redness by the direct-care staff". Based on interview and record verification, the facility failed to ensure that staff are trained on how to give a complete bed bath as well as how to use the heel bow protector on R1 who sustained a Stage IV pressure sore behind his left knee. Findings include: R1, per his face sheet, is a 48-year-old male whose diagnoses includes Profound Mental Retardation and Spastic Quadri paresis. On 05/24/03, per the nurses notes, "R1 was noted to have an open area behind his left knee area, 4 cm. in diameter and 2 cm. in depth. This Stage IV pressure sore was seen when staff pulled off the heel bow protector from his left knee exposing an open area with fascia and tendon exposed". Interviews with E5, E7, E9, E10, E11, E12, E13, E14, E17 (habilitation aides) and Z3 (agency aide) stated that at some point they gave R1 a bed bath but did not totally remove the heel bow protector that was on his left knee while doing the bed bath. When interviewed on specific times for the heel bow protector being on and off for R1, all said staff stated they did not know. E3 (nurse coordinator) was interviewed on 05/30/03, at 2:15p.m. E3 stated, "To prevent pressure sore on the knee, the heel bow protector is kept on R1 except during bathing; but we don't have a doctor's order. It's an informal thing we do." Per record verification and interview, there is no documentation as to when the heel bow protector was first used on R1's left knee". |