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BROKEN ARROW, OK – Nursing Home Failed to Prevent Stage 3 Pressure Ulcer; No Documentation of Sore Found in Records

VILLAGE HEALTH CARE CENTER

LOCATED: 1709 SOUTH MAIN, BROKEN ARROW, OK 74012

VILLAGE HEALTH CARE CENTER 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 CARE TO PREVENT THE DEVELOPMENT OF PRESSURE ULCERS

LEVEL OF HARM – ACTUAL HARM

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, it was determined the facility failed to provide care to prevent the development of pressure ulcers for one (#2) of one resident reviewed for pressure ulcers. The facility failed to: a) implement interventions for the prevention of pressure ulcers for the resident, and b) provide care and treatment in a manner to promote healing of pressure ulcers for the resident. On 07/27/14 documentation noted the resident had  developed an open stage three pressure ulcer. The facility’s census and condition report documented three residents had pressure ulcers which were in-house acquired.

Continuing: The comprehensive assessment, dated 06/15/14, documented the resident was severely impaired for daily decision-making, had delusions, required extensive assistance with the activities of daily living, required extensive assistance with bathing, and was incontinent of bowel and bladder. The assessment documented the resident had no pressure ulcers.

Continuing: The nurses’ notes, dated 06/02/14 through 07/27/14, were reviewed. The nurse’s notes documented no details regarding the development of the resident’s pressure ulcer. The nurses’ notes had no documentation regarding the size, depth, location, drainage, or stage of the ulcer. The notes did not document the physician had been notified or the treatment orders which were received. A physician’s orders [REDACTED]. The skin assessments/wound care sheets documented the resident’s pressure ulcer was first observed on 08/01/14. The record documented the pressure ulcer was a stage three ulcer. The report documented no measurements or assessment of the ulcer on 08/01/14. The nurse’s notes, dated 08/06/14, documented the resident was out of the facility for evaluation of rectal bleeding and returned to the facility on [DATE]. The skin assessment/wound record for 08/11/14 documented the wound was located on the coccyx, was a stage three ulcer.

Continuing: The LPN stated resident #2 had no skin issues upon admission and the pressure ulcer developed on 07/27/14. The LPN was asked to review the nurses’ notes. The LPN stated the notes did not document the pressure ulcer or notifications. The LPN stated the notes and treatment records did not document baseline measurements or the condition of the ulcer. The LPN stated she could not state the reason there were no documented details regarding the ulcer. The LPN was asked how the resident suddenly had a stage three pressure ulcer. The LPN stated she could not state the reason the resident had a stage three ulcer. The LPN was asked to review the Braden Scale skin assessments. The LPN stated the assessments were incorrect and the resident was at high risk for pressure ulcers.

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.

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