§ 483.25 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.
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Observations:
Based on clinical record review and staff interviews, it was determined that the facility failed to ensure care and services are provided in accordance with professional standards of practice related to wound assessments for one of six residents reviewed (Resident 5).
Findings include:
Review of Resident 5's clinical record revealed diagnoses that included atherosclerosis (buildup of plaque in the walls of arteries causing reduced blood flow) and type two diabetes mellitus (the body does not make enough insulin or cannot use it as well as it should).
Review of Resident 5's nursing progress notes revealed a note dated June 2, 2024, at 10:44 PM, that stated, "called Gentiva Hospice RN [Registered Nurse] about resident wound deterioration to LLE (left lower extremity) who stated to refer to wound team asap on Monday, covering dressing applied for now, area cleansed as ordered, MD notified, left message for Family member."
Review of progress note dated June 3, 2024, at 10:35 PM, stated, "Resident started on doxycycline 100 mg for left shin wound. No adverse effect noted, tolerated well. Vitals stable. Took all meds without difficulty and fluids. Pain management effective."
Review of Resident 5's wound and skin note dated June 3, 2024, revealed the wound consultant nurse practitioner documented maggots were present in Resident 5's left anterior shin wound and ordered the wound to be cleansed with 0.125% dakins solution (diluted bleach wound cleansing solution), dakins moistened fluffed gauze to the base of the wound and secured with bordered gauze twice daily and as needed. A wound and skin note dated June 5, 2024, from the wound consultant nurse practitioner documented no live maggots were present in Resident 5's left anterior shin wound.
Review of Resident 5's clinical record revealed no assessment of the wound and no documentation of maggots present in the wound in the progress notes.
Further review of Resident 5's clinical record failed to reveal evidence that the facility nursing staff continued to monitor or assess Resident 5's wound after the maggots were identified.
A staff interview on July 11, 2024, at 10:35 AM, with Employee 2 (Registered Nurse) revealed, Employee 2 was one of the registered nurse supervisors for the building the evening of June 2, 2024. Employee 2 stated that she was notified around 9:30 PM - 10:00 PM by the licensed practical nurse on the floor that Resident 5's wound looked different than it had previously. Employee 2 stated she went and assessed it (she said she had never seen it prior). Resident 5's left shin "wound was shiny black with something moving deep down in it".
A staff interview on July 11, 2024, at 12:37 PM, with Employee 1 (Nurse Practitioner) revealed Employee 1 arrived at the facility June 3, 2024, for wound rounds. The wound nurse at the facility informed Employee 1 that there was a concern of possible maggots in Resident 5's wound. Employee 1 immediately assessed Resident 5's wound and confirmed there were maggots in the wound.
A staff interview on July 10, 2024 at 12:30 PM, with the Director of Nursing revealed Resident 5 did have maggots in his left shin wound. She stated the physician was notified and orders were initiated to cleanse the wound with dakins solution several times a day and keep the wound covered.
28 Pa. Code 201.18(b)(1) Management
28 Pa. Code 211.12(d)(1)(5) Nursing services
| | Plan of Correction - To be completed: 08/11/2024
This Plan of Correction constitutes my written allegation of compliance for the deficiencies cited. However, submission of this Plan of Correction is not an admission that a deficiency exists or that one was cited correctly. This Plan of Correction is submitted to meet requirements established by state and federal law.
No ill effects are noted as a result of the deficiency. A nursing clarification note was added to the medical record that detailed the presence of maggots in resident #5's wound. A new PCC order set will be introduced that requires the nurses to document the ongoing monitoring and/or assessment of the resident wounds.
The facility DON or designee will review the previous month of wound care provided to residents for evidence of nursing assessments of the wounds in the progress notes, and for evidence of documented ongoing nursing monitoring or assessments.
The DON or designee will in-service the facility nursing staff that resident wounds must have documented assessments and ongoing documentation of the monitoring and/or assessments of those wounds.
The DON or designee will audit the resident wounds records for evidence of documented nursing assessments of the wounds, and ongoing documentation of monitoring and/or assessments of those wounds, weekly x 4, then monthly x 3 months. Results of the audits will be submitted to the Quality Assurance and Performance Committee.
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