PEAK RESOURCES-OUTER BANKS
LOCATED: 430 WEST HEALTH CENTER DRIVE, NAGS HEAD, NC 27959
PEAK RESOURCES-OUTER BANKS 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**
Review of Resident #11’s care plan initiated 4/29/16 revealed the resident was care planned for a pressure ulcer on the sacral area. The goal was that the resident’s pressure ulcer would decrease in size by next review. The interventions were to measure and record descriptions of the area, location, and size weekly, and to treat the area per physician orders.
Review of the resident’s quarterly minimum (MDS) data set [DATE] revealed the resident was assessed as having an unstageable pressure ulcer. The measurements of the pressure ulcer were 2.5 centimeters by 2.0 centimeters.
Review of Resident #11’s progress note dated 10/5/16 revealed during the routine dressing change to sacral pressure ulcer, Treatment Nurse #2 noted a large 6 centimeters by 6 centimeters soft fluid-filled packet at the wound. The skin color at the wound was noted to be red. Treatment Nurse #2 notified the Medical Director and an appointment was scheduled with Physician #1 the next day.
Review of a wound care physician’s consult note dated 10/6/16 revealed Physician #1 assessed Resident #11’s pressure ulcer at his doctor’s office. The assessment revealed the sacral ulcer had increased pain and redness. A large abscess was noted to be 12 centimeters by 12 centimeters by 5 centimeters on the resident’s sacrum. Physician #1 performed an incision and drainage of the abscess and discovered 6 inches of fine mesh gauze in the subcutaneous tissue.
During a telephone interview on 11/30/16 at 12:20 PM, Physician #1 stated when he observed Resident #11 on 8/11/16 he did not observe any fine mesh gauze in the wound. He further stated he only continued the ordered [MEDICATION NAME] dressing following this visit. Physician #1 stated that the facility placed a fine mesh gauze in the pressure ulcer on the sacrum intentionally or unintentionally at some point while the wound was still open. He further stated the gauze was either lost or forgotten about and the wound healed over the gauze. Physician #1 further stated that he had no doubt the gauze was the cause of the abscess that Resident #11 developed and he treated on 10/6/16. Physician #1 stated that someone in the facility’s staff had made a mistake and either not followed the order correctly or had lost a gauze in the wound somehow. He further stated that the fine mesh gauze should not have been left in the wound.
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.
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 have helped many already and we can help you and your loved one as well by filing a state complaint, hiring a specialized nursing home attorney or helping 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.
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