COLORADO SPRINGS, CO-PIKES PEAK CENTER

Findings include:
I. Cross-reference citations

Cross-reference F689: The facility failed to ensure resident safety with accident hazards. The facility’s failure to identify falls and address the falls with major injuries resulted in the facility being cited at a harm G level.

Cross-reference F684: The facility failed to receive treatment which was in accordance with professional standards of practice. The facility’s failure to identify and provide treatment in accordance with professional standards was cited at a harm G level.

Cross-reference F686: The facility failed to prevent the development of unstageable pressure injury. The facility’s failure to identify and prevent the pressure ulcer was cited at a harm G level.

Cross-reference F697: The facility failed to manage a resident’s pain. The facility’s failure to treat the resident’s pain was cited at a harm G level,

Cross-reference F677: The facility failed to ensure dependent residents received assistance with activities of daily living (ADL).

Cross-reference F679: The facility failed to ensure an ongoing resident centered activities program to meet the needs and interests of residents.

Cross-reference F695:The facility failed to ensure respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan.

ULCER CARE

Facility failures contributed to Resident #62, an at risk resident, developing avoidable pressure injury to the left heel and worsening pressure injury to the right heel. Specifically, the facility failed to timely identify the resident’s wheelchair footrest was inadequate, causing unrelieved pressure to the resident’s heels. Moreover, the facility did not notify the responsible party or the primary care physician of the new left heel wound and failed to develop a person-centered care plan for the left heel wound. The facility’s failures contributed to Resident #62’s prior right heel callus progressing to an unstageable pressure injury and contributed to her developing a new deep tissue injury to the left heel.

Additionally, the facility failed to:
-Ensure Resident #103, who was at high risk for skin breakdown, did not develop an avoidable pressure injury and an identified water blister was accurately documented; and,
-Ensure Resident #121 had interventions in place to prevent the development of a pressure injury, and to keep it from worsening.

RESIDENT PASSES AFTER FALL AT FACILITY

The 3/15/21 hospital records, provided by the DON on 3/22/21 at 4:00 p.m., revealed Resident #123 arrived at the hospital non-responsive except to touch with eye movement and incoherent words. The 3/16/21 computed tomography scan (CT scan) revealed she had a hematoma (pocket of blood inside the body) with a slow bleed. The injury was inoperable because of her frail state and she was transferred to an inpatient hospice unit. The resident passed away on 3/17/21.
The facility’s fall investigation, received at survey exit on 3/23/21, identified the root cause of the fall was lethargy and oxygen saturation levels were low.

(Cross-reference F684)
4. Facility failure The facility lacked evidence it had recognized and addressed her fall risks, including weakness, in an effort to keep her safe.

Resident #123’s daughter was interviewed on 3/23/21 at 9:30 a.m…..She said the resident was admitted to a hospice inpatient unit and passed away on 3/17/21 from the injuries of her fall. 

MULTIPLE PATIENTS ON OXYGEN DESPITE IT NOT BEING IN THEIR CARE PLAN 

On 3/11/21 at 10:59 a.m., Resident #71 was observed in his room. He was wearing an oxygen nasal
cannula. Resident #71’s oxygen concentrator was set on two liters of oxygen per minute. The oxygen tubing was not labeled with the date it was replaced.

Review of Resident #71’s comprehensive care plan revealed the resident did not have a care plan for the use of oxygen.

On 3/23/21 at 8:49 a.m., Resident #29 was observed in his room. He was not wearing oxygen. There was no oxygen concentrator or portable oxygen tank observed in the resident’s room. Resident #29 said he did not use oxygen.

Review of the resident’s comprehensive care plan revealed the resident did not have a care plan for the use of oxygen.

On 3/23/21 at 8:53 am., Resident #79 was observed in her room. She was wearing an oxygen nasal
cannula. Resident #79’s oxygen concentrator was set on four liters of oxygen per minute. The resident said she was on oxygen all the time.

Review of the resident’s comprehensive care plan revealed the resident did not have a care plan for the use of oxygen.

INADEQUATE STAFFING 

Facility failed to provide sufficient nursing staff with
the appropriate competencies and skills to ensure the residents received the care and services they required as determined by resident assessments and individual plans of care.
Specifically, the facility failed to consistently provide adequate nursing staff which considered the acuity and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] .
As a result in inadequate staffing, the facility failed to perform activities of daily living (ADL) cares for residents including assistance for residents for meal assistance, deliver meal trays timely to maintain the foods integrity, implement measures to prevent pressure ulcers

Cross-reference F-677, Maintain activities of daily living for dependent residents;
Cross-reference F-686, Treatment, prevent pressure ulcers;
Cross-reference F-804, Palatable food;
Cross-reference F-684, quality of care;
Cross-reference F-689, Accident hazard; and;
Cross-reference F-695, Respiratory therapy.