KINDRED NURSING AND REHABILITATION – BASHFORD
LOCATED: 3535 BARDSTOWN, LOUISVILLE, KY 40218
KINDRED NURSING AND REHABILITATION – BASHFORD 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, record review, facility policy review, review of the Lippincott Manual of Nursing Practice, and Mosby’s Long Term Care Assistants, it was determined the facility failed to ensure residents at risk for pressure ulcers received the necessary treatment and services to prevent the development of new pressure ulcers for one (1) of twenty-two (22) sampled residents (Resident #8). The facility assessed Resident #8 with an avoidable pressure ulcer, on 06/17/15, related to the indwelling catheter was not stabilized by anchoring the tubing to reduce the complications of skin breakdown. The resident’s thigh laid on the tubing and connector and developed a blistered area that sloughed the top layer of skin and progressed to a pressure area.
Review of the Lippincott Manual of Nursing Practice, 10th Edition, 2014, Section Pressure Ulcers, page 183, revealed pressure applied for longer than 2 hours could produce tissue destruction; healing cannot occur without relieving the pressure. Section Catheterization, page 781, revealed properly securing the catheter prevented catheter movement and traction on the urethra; keeping the tubing over the patient’s leg helps prevent kinking or forming loops of stagnant urine; and, maintaining unobstructed urine flow to prevent reflux of contaminated urine into the bladder or pooling of urine in the loops of tubing.
Review of the Comprehensive Care Plan, dated 06/25/13, for Resident #8 revealed goal revisions on 02/18/15 and the target date for 08/27/15. Problems on the care plan included the resident was at risk for skin breakdown related to decreased mobility, [MEDICAL CONDITION] (swelling), and an indwelling catheter. Interventions listed on the care plan included ensuring the catheter tubing was positioned properly. In addition, the care plan included the resident was at risk for complications associated with [MEDICAL CONDITION], initiated on 06/25/13, and a goal target date of 08/27/15. Interventions included to monitor for signs and symptoms of injury, infection or ulcers.
Observations of Resident #8 during the initial tour, on 06/14/15 at 3:20 PM, revealed a bedside drainage bag in a dignity bag for an indwelling catheter was placed on the resident’s left side of the bed.
Observation, on 06/16/15 at 2:20 PM, revealed Resident #8’s indwelling catheter bedside drainage bag was in a dignity bag placed on the resident’s left side of the bed.
Observation, on 06/17/15 at 10:40 AM, revealed Resident #8’s indwelling catheter bedside drainage bag was in a dignity bag placed on the resident’s left side of the bed.
Observation, on 06/17/15 at 2:45 PM, revealed during the dressing change and skin assessment with the Advanced Registered Nurse Practitioner (ARNP), Resident #8 requested the ARNP to assess his/her left posterior thigh. A new area was identified that measured 9.5 cm X 2.5 cm X 0.1 cm. deep, the skin was pink and shiny with the top layer of the blister missing.
Observation at the time of the skin assessment revealed the resident’s indwelling catheter tubing was not anchored to prevent the resident from laying on top of it.
Interview with the Director of Nursing, on 06/17/15 at 4:00 PM, revealed the facility policy included the indwelling catheter tubing should be anchored to maintain positioning to keep the tubing from under the resident. She stated the ARNP gave the facility a new order to anchor the catheter with paper tape. She reported tape was also a method to secure the indwelling catheter tubing. She stated a resident laying on the catheter tubing had the potential of blistering of the skin and skin breakdown. She reported the resident’s break in the skin integrity could have been prevented by the catheter tubing not being left under the resident leg.
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.
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