GRACE LIVING CENTER-BROOKWOOD
LOCATED: 940 SOUTHWEST 84TH STREET, OKLAHOMA CITY, OK 73139
GRACE LIVING CENTER-BROOKWOOD 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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, it was determined the facility failed to prevent the development of an avoidable moisture-associated skin damage (MASD) area for one (#16) of three sampled residents reviewed for assistance with activities of daily living.
On 09/07/16 at 1:10 p.m., the resident was observed in the main dining area seated upright in a reclining positioning chair. He was observed to eat a meal as he was assisted by a family member. They were asked if his needs were being met in a timely manner by the staff.
The family member responded the care was good, except she wished he could be changed more often. She was asked how often they changed him. She stated, I’m sure it’s only done when they get him up and when they put him back in bed. The resident was observed to be covered from his chest to his ankles with a blanket as he ate. He was asked if he was cold. He stated, I’m freezing.
The family member re-positioned the blanket covering the resident. When the blanket was moved a strong odor of urine permeated the immediate area.
The spouse was asked to raise the blanket covering the resident’s lower body. As the blanket was raised the resident’s pants were observed to have a darkened wet spot covering the entire crotch area.
The odor of urine was very strong. The family member was observed to fan her face with her hands to clear the odor from her face.
The family member stated, this is how I find him every time I come in to feed him his lunch. She was asked how often she came in to assist him with his meal. She stated she came every day.
The resident was asked when he had last been re-positioned or had incontinent care provided. He stated he had not been provided care or re-positioned since he had been assisted out of bed that morning. He was then asked if he could recall what time he was assisted out of bed, and he stated, they usually get me up around 8:00 a.m., if not before.
The resident was asked if he thought being wet was contributing to his being so cold. He stated he hadn’t thought about that but it made sense.
At 2:00 p.m., CNA #1 and the restorative aide (RA), entered the room and placed the resident in bed using a mechanical lift. When the resident was lifted from the positioning chair, the cushion on the chair was observed to be wet and odorous. The sling used to transport the resident from the chair to the bed, was also wet and odorous.
As the resident was positioned on the bed, his blue sweat pants were observed to be wet over the entire crotch area and odorous. The pants were removed, and then the brief. The brief was completely saturated with urine and feces. The RA provided peri-care as the CNA positioned the resident for the care. The RA was observed to wipe and clean the peri-area thoroughly around the penis and top of the scrotal area. The resident was then repositioned onto his left and right side to cleanse the buttock area of feces He was then positioned supine in bed and the two aides stopped and looked at the surveyor. They were asked if they were finished. The RA stated, well no.
They were asked if the resident’s right leg could be lifted to expose the crease of the leg at the hip area. The resident’s leg was lifted as the RA cleansed the crease in a downward motion with a slightly damp incontinent wipe. The RA was observed to wipe the area very gently.
The resident was observed to tense up and grimace when the staff member wiped toward the bottom of the anus area. The CNA then stated the resident had, had the runs the past couple of days.
The aides were asked to raise the resident’s left leg so the anus area could be viewed as the area was cleansed.
The anus area was observed to have three dime-sized open, bleeding, excoriated areas on the left side of the buttock near the anal area.
As the staff cleansed the feces from the anal area, the resident was heard to say, you talk about something that hurt, now. Whew. That’s sore. The scrotum was also observed to be reddened and tender as it was cleansed.
The CNA was asked if those areas were there when he was changed earlier in the day, before going to activities. The CNA stated she wasn’t sure. The care provided was observed to take 25 minutes to complete.
At 2:30 p.m., LPN #2 was interviewed and asked when the resident’s last skin assessment was completed and what her findings were. She stated she had not completed one for the current week. She was asked if she knew of any wounds the resident may have. She stated the resident previously had only some blisters along his hip areas and on the lower back area. She was asked what she thought could have caused the blisters she found. She stated, probably from his briefs rubbing.
On 09/07/16 at 2:54 p.m., the director of nurses (DON) and corporate nurse #1 was interviewed. The DON was advised of the above observations and asked what their policy was regarding incontinent care and repositioning dependent residents.
She stated all residents were to be provided with care every two hours or more often if necessary. She further stated she generally watched out for dependent residents to ensure they were not being left too long in their chairs, and that staff re-positioned and changed them on a regular basis.
She was advised the resident was observed from 9:00 a.m., until 2:30 p.m., with no incontinent care or assistance with re-positioning provided during that time.
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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