LOCATED: 4490 VIRGINIA LOOP ROAD, MONTGOMERY, AL 36116
CEDAR CREST 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 GIVE RESIDENTS PROPER TREATMENT TO PREVENT NEW BED (PRESSURE) SORES OR HEAL EXISTING BED SORES.
LEVEL OF HARM –ACTUAL HARM
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review the facility failed to ensure RI (Resident Identifier) #1, a resident assessed to be at risk for pressure ulcer development, was turned and repositioned in bed to prevent pressure ulcer development. There was no plan of care in place to address RI #1’s risk for pressure ulcer development. As a result, RI #1 developed a stage three pressure ulcer on the left lower leg.
On 9/14/2016 at 8:00 a.m. RI #1 was asked how often he/she was turned. RI #1 said, only when they would bathe me. RI #1 was asked if staff provided repositioning during incontinent care. RI #1 repeated that repositioning only occurred during bathing. RI #1 was asked what kind of pillows or wedges were used for repositioning. RI #1 stated, they didn’t use any. I’ve been on my back since I’ve been here since April. RI #1’s head of the bed was observed elevated, with RI #1 lying on his/her back, with the left leg turned to the side with a pillow under the left ankle and the foot/ankle resting directly on the pillow. RI #1’s left heel was not floated (positioned with the heel elevated to eliminate pressure and prevent pressure ulcers).
On 9/14/2016 at 8:15 a.m. EI #3 was asked to observe RI #1 and describe what she saw. EI #3 said the left foot was floated on a pillow. When asked if the left leg was floated or lying on the pillow, EI #3 said, it’s lying on the pillow. When asked what area was to be floated, EI #3 said, the heel. When asked if she actually knew where RI #1’s wound area was, EI #3 said, she had not seen the area. When asked about the wound on the side of the leg/ankle and how pressure was being prevented with that area lying on the pillow, EI #3 said, it’s not. EI #3 was asked if she thought RI #1’s wound was on the heel. EI #3 replied, yes. When asked what she would do differently knowing the wound was on the side of the leg/ankle, EI #3 stated, I would use a wedge. EI #3 pointed to a wedge on the other side of RI #1’s room.
On 9/14/2016 at 2:10 p.m. EI #3 was again questioned about RI #1. EI #3 was asked what she had observed as to why RI #1’s left leg leaned to the left side. EI #3 said, I guess (RI #1) has no control over the left leg and that is why it leans to the left side. When asked how she usually found RI #1’s left leg positioned, EI #3 stated, I don’t look at the left leg until I get ready to turn (RI #1) and I find it the way you did this morning, laid over on the pillow. When asked why she thought RI #1 felt like repositioning was not being done, EI #3 replied, Maybe because we use the pillow and it is not really strong enough to turn (RI #1) and it just goes down flat. When asked if she had asked anybody for something stronger to use for a positioning device, EI #3 said, no. When asked why she had not told someone about the pillow not being strong enough, EI #3 stated, I didn’t think about it until you said (RI #1) didn’t feel (he/she) was being turned.
Personal Note from NHA – 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.
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