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Pikeville, KY – Plan of Care not Followed; Pressure Sore Developed

SIGNATURE HEALTHCARE OF PIKEVILLE

Located: 260 SOUTH MAYO TRAIL, PIKEVILLE, KY 41501

SIGNATURE HEALTHCARE OF PIKEVILLE was recently in November of 2013 by the DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES for the following deficiencies:

The following highlighted quoted text is only a portion of the full report/survey. The complete report/survey can be found here.

The facility had assessed Resident #1 to be at risk for impaired skin integrity prior to the diagnosis of a fracture to the left femur and developed a plan of care to address the prevention and development of pressure sores. However, the facility failed to follow the plan of care. In addition, the facility failed to revise the plan of care after the resident sustained the fracture to include when to remove the “pillow splint” to conduct an assessment of the resident’s skin that was covered by the “pillow splint.”

SERVICES BY QUALIFIED PERSONS/PER CARE PLAN

Based on interview, record review, and policy review, it was determined the facility failed to ensure care was provided in accordance with the resident’s Plan of Care.

Continuing: it was determined the facility failed to ensure one (1) of four (4) sampled residents (Resident #1) who entered the facility without pressure sores did not develop pressure sores.

Continuing: On 11/13/13, the facility transferred Resident #1 to the Emergency Room (ER) due to a change in the resident’s mental status. Upon Resident #1’s arrival to the ER on 11/11/13, 1he ER physician removed the “pillow splint” from the resident’s left leg and observed a 3.5 centimeter (cm) by 6.5 cm decubitus ulcer to the top of the left lower leg and purulent drainage on the “pillow splint.” In addition, the ER physician documented Resident #1 had a pressure area to the left heel that had black eschar (dead tissue).

Continuing: The aides stated they had not been directed to remove the resident’s splint and had left the splint intact. The aides said if the splint became soiled they notified the nurse in charge, and the nurses changed the splint.

Continuing: The Administrator and the Nurse Consultant stated they did not know if facility staff had removed the “pillow splint” from Resident #1’s left leg or why staff failed to identify the pressure areas to Resident #1’s left lower leg and the left heel.

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.

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One Response to “Pikeville, KY – Plan of Care not Followed; Pressure Sore Developed”

  1. Teresa Robinson says:

    My father had a bad experience at the same nursing facility! He was transferred to our local hospital and died there! We did file complaints that led to resignations and other changes!

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