SIGNATURE HEALTHCARE OF BOWLING GREEN
LOCATED: 550 HIGH STREET ST, BOWLING GREEN, KY 42101
SIGNATURE HEALTHCARE OF BOWLING GREEN was cited by the DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES for the following deficiencies:
PLEASE NOTE: The following highlighted quoted text is only a portion of the full report/survey submitted by DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES. The full report/survey can be found here.
FACILITY FAILED TO PROVIDE NECESSARY CARE AND SERVICES TO MAINTAIN THE HIGHEST WELL BEING OF EACH RESIDENT
LEVEL OF HARM – ACTUAL HARM
Provide necessary care and services to maintain the highest well being of each resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, record review, facility policy and procedure review, and Hospital Admission Record review it was determined the facility failed to provide services to maintain/attain the highest practicable physical, mental and psychosocial well-being. Resident #1’s was identified with a cyst to the back of the right hand on admission on 12/18/13. Staff completed wound assessments on the wound through 06/09/14 when the wound measured 7.0 centimeters (cm) x 6.9 cm. and was identified as having a foul odor and serosanguineous drainage. There was no documented evidence of further wound assessments until maggots were identified in the wound on 09/05/14. Interview on 09/16/14 at 8:08 AM; and, on 09/17/14 at 10:44 AM with the Assistant Director of Nursing (ADON) #1, revealed the right hand tumor was measured up until 06/09/14 but it was not measured after that time.
ADON #1 further stated the measurements were started back up on 09/12/14 because the new DON wanted staff to measure the resident’s right hand. The ADON revealed it was her responsibility to make sure that non-pressure skin condition records were completed, but the previous DON did not want to measure areas like Resident #1’s right hand. ADON #1 further stated if the DON did not want the non pressure wounds measured then we did not do it. Interview, on 09/17/14 at 5:16 PM with Registered Nurse (RN) #2, revealed maggots were found in the wound of Resident #1’s right hand between 11:30 PM and 1:00 AM on 09/05/14. Interview, on 09/16/14 at 10:03 PM with Licensed Practical Nurse (LPN) #4, revealed maggots were found on the dressing on the resident’s right hand and in the wound of Resident #1’s right hand on 09/05/14. Further interview revealed the treatment for [REDACTED]. Review of Telephone Physician Order, and Nursing Notes, dated 09/05/14, revealed Resident #1 was sent to the emergency room for wound determination to the right hand, and returned on 09/05/14 with an order for [REDACTED]. Review of the Comprehensive Care Plan for Infection, dated 09/05/14, revealed the resident had active infection in wound with interventions to administer medications as ordered and assess wound bed during dressing changes for any additional abnormalities. Review of Telephone Physician Order, dated 09/05/14, revealed to discontinue order to cleanse right hand with normal saline, apply dry dressing wrap with kerlix twice a day; and a new order to cleanse right hand growth with normal saline, apply dry dressing then wrap with kerlix every shift. However, review of the September 2014 Treatment Administration Record (TAR) revealed the new order for treatment every shift was not placed on the TAR until 09/10/14 and there was no documented evidence Resident #1 received the treatments to the right hand wound every shift from 09/05/14 through 09/10/14, on 09/12/14, and on 09/15/14. Interview on 09/18/14 at 9:24 AM and 3:19 PM with the Assistant Director of Nursing (ADON) #1 revealed she had taken the order on 09/05/14 for Resident #1 to change the treatment from twice a day to every shift. She stated the order would have to be put in the computer system to ensure it was printed on the TAR. She was unable to give an explanation as to why the order was not on the TAR prior to 09/10/14. Interview with the Director of Nursing (DON), on 09/16/14 at 8:06 AM, revealed she did not know why the wound was not measured because it had to be open to attract flies, and she had seen some skin assessments missing and some wounds were not measured. Further interview with the DON, on 09/17/14 at 9:20 AM, revealed the ADONs were supposed to measure pressure and non-pressure wounds. The DON further revealed she instructed staff that anything on the non-pressure sheet should have had a measurement. She stated the ADONs were aware they were supposed to measure the pressure and non-pressure areas. The DON further revealed the area on the resident’s right hand was only 3 cm x 3 cm upon admission, and had been noted as a cyst. The DON stated she was trying to figure out how it got from a cyst to present day. She stated she could not have made it clearer to staff that if they did not complete the admission assessment and non-pressure skin condition and pressure condition records there would be consequences. Interview, on 09/18/14 at 7:53 AM and 2:02 PM with Resident #1’s Physician revealed he did not expect maggots to be in the resident’s wound and if dressings are not changed they can get dirty and could become infected.
Personal Note from NHAA Advocates: NHAA shares with all the families of loved ones who are confined to nursing homes the pain and anguish of putting them in the care of someone else. We expect our loved ones to be treated with dignity and honor in the homes we place them. We cannot emphasize enough to family members of nursing home residents; frequent visits are essential to our loved ones’ well-being and safety. This nursing home and many others across the country are cited for abuse and neglect.
You can make a difference. If you have a loved one living in this nursing home or any other nursing home where you suspect any form of abuse or neglect, contact us immediately. We can help you file a state complaint, hire a specialized nursing home attorney or help you find a more suitable location for your loved one.
Contact us through our CONTACT FORM located on our website here below or on the sidebar or call our toll free hot line number: 1-800-645-5262
You can make a difference even if your loved one has already passed away.