|§483.35 Nursing Services|
The facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at §483.70(e).
§483.35(a)(3) The facility must ensure that licensed nurses have the specific competencies and skill sets necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care.
§483.35(a)(4) Providing care includes but is not limited to assessing, evaluating, planning and implementing resident care plans and responding to resident's needs.
§483.35(c) Proficiency of nurse aides.
The facility must ensure that nurse aides are able to demonstrate competency in skills and techniques necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care.
Based on a review of clinical records, select facility policies and employee personnel files and staff interviews, it was determined that the facility failed to ensure that nursing staff possessed the necessary competencies and skills to accurately provide physician ordered care, necessary nursing care and timely consistent monitoring of a resident's colostomy for adequate function, to prevent infection and skin impairment for one of seven residents reviewed (Resident CR1).
A review of Resident CR1's clinical record revealed admission to the facility on February 13, 2019, with a colostomy related to a malignant neoplasm of the transverse colon. Further review of the resident's clinical record revealed no indication of any skin issues around the colostomy/stoma site upon the resident's admission to the facility. The resident did have a midline (vertical cut made in the abdomen to allow access for a surgical procedure) surgical area upon admission. On March 2, 2019, the area measured 10 cm length x 2 cm width and 1 cm in depth. There was a small amount of odorless serous drainage pink/red in color. The area was described as macerated. A treatment of wet gauze wrapped with normal saline solution pack distal 1/3 of incision and cover with 4 x 4 dressings and Abdominal gauze pads, tape window and change twice daily.
According to review of nursing progress notes the resident's colostomy was changed on February 16, 2019, and February 27, 2019, for leakage. On February 23, 24, 2019 the colostomy bag and wafer had to be changed because they were loose.
On February 28, 2019, the resident was seen for a follow-up consultation for the resident's colostomy. A review of the request for consultation sheet, revealed that the resident's surgical incision at the colostomy site was extremely excoriated around the ostomy site. It was described as difficult to keep sealed with loose bowel movement leaking into the original incision site. The surgeon response was that the facility needed to "snap the ostomy bag together better."
A review of the resident's clinical record revealed no documented evidence that the area was excoriated around the colostomy site or that any interventions were in place to address the problem.
On March 5, 2019, however, there was a physician telephone order to apply duoderm closely surrounding the stoma site under the wafer. A review of the resident's March 2019 treatment administration records revealed no evidence that this physician order had been carried out.
When interviewed at 2:15 p.m., Employee 3 (Registered Nurse) stated it was facility policy to apply barrier cream as a routine part of ostomy care.
A review of the facility policy for Ostomy Care-Stoma Care last revised by the facility on September 5, 2017, revealed that "after the areas around the stoma was cleansed. Skin barrier was to be applied around the stoma, any skin treatment order was to be completed at the time and skin prep (a liquid film-forming dressing that, upon application to intact skin, forms a protective film to help reduce friction during removal of adhesives or used to prepare surrounding ostomy sites) "as needed" could be utilized." Employye 1 confirmed the physician order from March 5, 2019, and the absence of documented evidence that it had been implemented by nursing staff. Employee 1 was unaware that the physician order had not been carried out prior to surveyor inquiry.
Clinical record documentation revealed that on March 6, 2019, there was increased drainage, described as thick green purulent, noted from the resident's abdominal incision. A physician order to culture the wound drainage to the abdominal incision area was obtained on March 7, 2019. The drainage tested positive for methicillin resistance staphylococcus aureus.
A review of a non-pressure skin condition record completed for the resident dated March 10, 2019, (first indication that the facility had measured and described the area for tracking purposes) revealed that the impaired area to the resident's colostomy site was noted to be "not present on admission." The area was noted to be excoriated and measured 15 cm x 10 cm.
On March 7, 2019, and March 15, 2019, according to review of nursing progress notes, the stoma to the resident's colostomy was described as red, with no drainage to the area.
The area to the resident's surgical site/ abdomen was measured on March 13, 2019, and revealed that the area measured 10 cm x 2 cm x 2 cm depth with a large amount of green drainage.
According to review of the resident's non-pressure skin condition record dated March 17, 2019, the area to the resident's colostomy remained 15 cm x 10 cm, but was now described as a red macerated moisture associated skin disorder.
On March 21, 2019, the resident was seen for a post-operative visit. The resident's son accompanied the resident and told the surgeon that the facility was having difficulty with the seal on the ostomy and that it was continually leaking into the midline incision. When the surgeon examined the ostomy site he determined that it was functioning, but had a poor seal on the wafer at the site of the incision. The surgeon's plan was to discuss ostomy care with a wound care ostomy nurse at the hospital to explore outpatient services that the facility could use to improve the fit of the ostomy device.
The resident's clinical record revealed a physician order was received on March 22, 2019, for a consultation between facility staff and an Ostomy nurse, which was completed via telephone. Following this consultation, orders were received to dust the ostomy site irritated skin with stoma powder on all raw areas, brush off lightly with gloved finger so as not to cake powder. Pat with non sting skin prep or skin prep. Subsequently the resident was transferred out to the hospital on March 26, 2019.
When interviewed at 2:15 p.m. Employee 3, RN stated that the facility was having a very difficult time getting the resident's colostomy to stop leaking. She stated that the issue became so extensive they had utilized briefs on the resident, although the resident was continent of urine. Employee 3 stated that the problem had improved after the Ostomy nurse had provided guidance to facility nursing staff and orders via the telephone related to care of the device to prevent leakage. Once the resident returned to the facility following his admission to the hospital on March 26, 2019, the resident's skin and the seal of the resident's colostomy had improved as had the leakage.
According to review of the facility's Colostomy, Ileostomy and Nephrostomy Care Competency Checklist, competencies were completed for both licensed practical nurses and registered nurses at the facility in January 2019.
A review of the competencies revealed that the competency review was related to routine changing and care of the device. However, this review did not address any issues/complications which might arise, related to the use of the device including seal, leakage, possible skin irritation and infection control during leakage.
28 Pa. Code 211.12 (a)(c)(d)(1)(3)(5) Nursing services
Previously cited: 1/31/19,10/26/18,9/9/18
28 Pa. Code 211.5(f)(g) Clinical records
Previously cited: 10/26/18,9/9/18,7/24/18.6/4/18.
28 Pa. Code 201.20(a)(d) Staff Development
28 Pa. Code 201.19 Personnel policies and procedures
| ||Plan of Correction - To be completed: 05/30/2019|
1. Resident CR1 no longer resides in the facility.
2. Residents with colostomies will have their stoma sites assessed for any skin issues and if found will be reported to physician for follow up care as ordered.
3. Residents with ostomies will be reviewed at Wound Meeting to discuss and address any issues/complications that may arise.
Staff will be educated on the P&P for ostomy care and will include reporting and follow up for issues and complications that may arise including leakage, skin irritation and infection control.
Competencies for ostomy care will be revised to include identification and treatment of issues that may arise.
4. An audit of residents with ostomies will be completed with attention to condition, treatment, Physician orders and documentation.
The results of the audits will be presented to QAPI.