STATESBORO, GA-EAGLE HEALTH AND REHABILITATION

Develop and implement a complete care plan that meets all the resident’s needs, with timetables and actions that can be measured.

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Based on observations, staff interviews, record review, and a review of the facility’s policy titled, Patient’s Plan of Care, the facility failed to follow residents’ individualized care plans directing staff to apply barrier cream after an incontinence episode for 2 of 3 residents (#24 and #31) who received incontinence care. This failure had the potential for residents to not receive treatment and/or care according to their needs and may cause adverse consequences.

Findings included:

The facility’s policy titled, Patient’s Plan of Care, with a review date of 12/04/2021, indicated, Each patient will have a person-centered comprehensive care plan developed and implemented to meet his other preferences and goals, and address the patient’s medical, physical, mental and psychosocial needs.

A review of R#24’s Face Sheet revealed the facility admitted R#24 with a diagnosis of anoxic brain injury.

The care plan revised on 11/22/2022 indicated R#24 was at risk for skin breakdown. Interventions included using barrier cream after each incontinent episode to protect the resident’s skin.

Observation on 03/01/2023 at 9:40 a.m., Certified Nursing Assistant (CNA) #2 removed R#24’s brief and removed a bowel movement using a disposable wipe. After cleaning up the bowel movement, the CNA#2 placed a clean brief on the resident without applying a moisture barrier on the resident’s skin.

Interview on 03/01/2023 at 9:55 a.m., CNA#2 acknowledged she had not applied any moisture barrier, although she said she typically placed barrier cream on a resident after she bathed a resident if the resident’s skin was red. CNA#2 stated she had not put any barrier cream on R#24 because she had no barrier cream with her in the room but added that barrier cream was kept on the cart in the hall. She stated she had been helping with R#24.

Interview on 03/01/2023 at 10:00 a.m., CNA#3 stated barrier cream was used for any resident who wore briefs and had a risk of skin breakdown.

Interview on 03/01/2023 at 10:50 a.m. with Licensed Practical Nurse (LPN) #1 stated interventions to prevent skin breakdown included applying a moisture barrier after each incontinent episode. The LPN#1 stated R#2 was at risk for skin breakdown due to incontinence and would need moisture barrier applied after incontinence care. The LPN#1 stated if the care plan directed staff to apply moisture barrier the expectation would be for staff to follow the care plan.

Interview on 03/01/2023 at 12:17 p.m. with CNA#5 stated she was assigned to care for R#24 for the shift. The CNA#5 stated that when she provided incontinence care for R#24, she did not routinely apply barrier cream after an incontinence episode.

Interview on 03/01/2023 at 12:19 p.m. with Director of Nursing (DON) stated she expected staff to use barrier cream after incontinence episodes and expected staff to follow the care plan for the residents.

Interview on 03/10/2023 at 2:30 p.m. the Administrator stated he expected staff to follow the care plans for the residents.

The facility’s policy titled, Patient’s Plan of Care, with a review date of 12/04/2021, indicated, Each patient will have a person-centered comprehensive care plan developed and implemented to meet his other preferences and goals, and address the patient’s medical, physical, mental and psychosocial needs.

A review of a Face Sheet revealed the facility admitted R#31 with hemiplegia (limited movement) following a stroke affecting the left non-dominant side, heart failure, and chronic obstructive pulmonary disease.

A review of R#31’s care plan, with a revision date of 01/25/2023, revealed the resident was at risk of developing further skin breakdown. Interventions included applying a barrier cream after incontinence episodes.

An observation was made on 03/01/2023 at 9:00 a.m. with the Clinical Care Coordinator (CCC) providing wound care. The resident’s brief was wet and soiled. The CCC removed the resident’s bowel movement using a disposable wipe without applying barrier cream to the resident’s skin.

Interview on 03/01/2023 at 10:50 a.m. with Licensed Practical Nurse (LPN) #1 The LPN#1 stated
interventions to prevent skin breakdown included applying a moisture barrier after each incontinence episode. The LPN#1 stated R#31 was at risk for skin breakdown due to incontinence and would need moisture barrier applied after incontinence care. The LPN#1 stated if the care plan directed staff to apply moisture barrier, the expectation would be for staff to follow the care plan.

Interview on 03/01/2023 at 12:54 p.m. with the CCC stated there had been no reason she had not applied moisture barrier to R#31’s skin, but would have applied the barrier if the resident’s skin had been red. The CCC stated the care plan should be followed.

Interview on 03/01/2023 at 12:19 p.m. with the DON stated she expected staff to use the barrier cream after incontinence episodes and expected staff to follow the care plan for the residents.

Interview on 03/10/2023 at 2:30 p.m. with Administrator stated he expected staff to follow the care plans for the residents.