CLASS B CITATION-- PATIENT CARE
REGULATION VIOLATION: CFR 483.25 F309 Quality of Care
Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care.
During an investigation of a complaint that began on October 25, 2011, it was determined that the facility staff failed to ensure Resident A was provided position changes and preventative skin care in accordance with Resident A's needs to maintain his highest practicable physical and mental well-being, which resulted in a scrotal injury requiring surgical intervention for Resident A.
Record review showed Resident A was transferred to the acute care hospital from the skilled nursing facility (SNF 1) on October 10, 2011 at approximately 7:00 PM. The hospital emergency department (ED) admission records indicated that Resident A arrived at 7:24 PM, with a scrotal injury that was bleeding. Resident A was found at SNF 1 with "De-gloving (scrotal skin being sheared off, usually as a result of trauma) of both testes."
The hospital admitting physician's history and physical note (H&P) dated October 10, 2011, indicated the following, "The patient was admitted to the hospital under the care of the internal medicine team with a diagnosis of scrotal avulsion (tearing away or - separation of skin from scrotum) and suspicion of adult abuse and was taken to the operating room on the morning of October 11, 2011 for debridement (surgical removal of any damaged tissue) and closure of scrotal avulsion."
A review of the ED triage assessment notes dated October 10, 2011 at 7:24 PM, indicated Resident A's pain scale rating was "9-10" (on a scale of 0 to 10, 0 = no pain, 10 = worst pain).
Further review of the hospital records indicated Resident A was aphasic (a condition in which speech and language function is disordered because of a brain injury), and had limited movement in upper extremities (arms and hands), and as a result, Resident A was bed bound. A progress note dated October 17, 2011 at 4:30 AM, showed documentation that indicated the resident's upper arms/hands and lower legs were contracted on the right and left sides (a permanent tightening of muscles, tendons, and ligaments, which results in loss of motion in the affected joints).
A review of the urologist's (a physician who specializes in the practice of the urinary tract) history and physical notes dated October 11 , 2011 at 12:37 PM indicated that the injury appeared to be, "An incision with de-gloving of the scrotum."
During a telephone interview with the urologist on November 3, 2011 at 9:30 AM, he stated the type of injury Resident A had "doesn't just happen." He further stated that he did not believe Resident A caused the injury to himself, given the resident's physical limitations of movement in the arms and hands, and he did not believe the injury to be self-inflicted. The physician further stated the resident was in a lot of pain, and the injury was a clean tear; "In my opinion, no way could the resident do that to himself; someone cut his scrotum." He stated his concern was that someone "forcefully tore it or cut it," because he (the urologist surgeon) did not have to debride any of the skin during the repair procedure. The physician stated that photographs were taken of the injury before and after the surgical repair. The four photographs were obtained and reviewed which showed an inverted U shaped wound to Resident A's scrotum. There were no jagged skin edges or tears evident; the edges appeared clean and precise.
Further review of the hospital records showed a police report was taken at the hospital on October 11, 2011 at 1:00 AM. A review of the police report included three photographs of Resident A's scrotal injury, three photographs of his hands and four photographs of his bed/room at SNF 1.
A review of the acute care hospital records showed that Resident A was hospitalized for nine days and on October 18, 2011, he was discharged and transferred to a different skilled nursing facility (SNF 2).
On October 25, 2011 at 2:30 PM, an unannounced visit was made to SNF 2, and an interview was conducted with Resident A's primary care giver, a certified nurse assistant (CNA 1). She stated Resident A had arthritis to his entire body and only moved his head from side to side, and that two people were required to move or transfer him and that two people were required to pry his arms away from his upper body. She stated a lift was used to transfer him in and out of the bed. She stated, "He doesn't have full movement or extension in his upper arms." When asked, CNA 1 stated that she did not think he could straighten out his arms because she had not seen him do it.
During an observation and interview conducted with Resident A, on October 25, 2011 at approximately 2:35 PM, accompanied by Resident A's CNA 1, the resident was in bed, awake and alert; he had minimal speech ability but was able to respond with a nod of his head, yes or no, and could mumble some words. CNA 1 asked the resident to grab and squeeze her hands as tight as he could. The demonstration confirmed Resident A had limited mobility and weakness in both arms and hands. Resident A's upper limbs were predominantly flexed at the elbows, with forearm and hands midline (in the middle) toward the chest area, and his hands were clenched closed.
Resident A was asked for permission to look at his wound. When Resident A was asked how it happened, Resident A mumbled and shook his head as if to say he did not know how it happened. He denied scratching himself on the groin area; he denied self-inflicting the injury. When asked again how it happened, Resident A shook his head from side to side and mumbled, "I don't know." When asked if someone deliberately injured him, he shook his head indicating "No". Resident A then closed his eyes and when asked if he did not want to talk about the incident, he nodded to indicate he did not want to talk about it.
During the observation, it was also noted that Resident A's legs were contracted upward, bent at the knees and inward with one knee over-lapping the other knee. Resident A required extensive assistance by CNA 1 to separate his legs to allow for a visual examination of the scrotal area injury.
An unannounced visit was made to the facility (SNF 1) on October 26, 2011 to review the medical record for Resident A.
A review of Resident A's admission face sheet indicated he was initially admitted on February 27, 2004, with diagnoses that included a history of traumatic brain injury post automobile accident, aphasia (a condition in which speech and language function is disordered because of a brain injury), gastrostomy feeding tube (a tube inserted through a hole outside the abdomen and into the stomach to deliver nutrition), degenerative arthritis (a disease in which deterioration of structure or function of tissue occurs).
A review of the rehabilitation therapy notes (PT/OT) dated December 21, 201 0 to December 28, 2010, indicated that Resident A had severe contractu res of the lower extremities and required extensive assistance with mobility which included an assistive device called a Hoyer lift to transfer the resident in and out of bed. The evaluation notes indicated Resident A had a limited range of motion (ROM, which refers to the extent of movement of a joint to its full potential) of ten degrees (slightly bent) for the knees. [Normal ROM at the knee is considered to be zero degrees of extension (completely straight knee joint) to 135 degrees of flexion (fully bent knee joint)], and a strength level of -2 to -3 (measurements in the minus range means no strength or movement to that area). A review of the occupational therapy (OT) notes indicated Resident A's mobility to the upper extremities was limited due to increased tone.
During an interview with the physical therapist (PT) on October 26, 2011 at 4:30 PM, he stated that Resident A had right side paralysis with a trace of muscle twitching in the legs; the resident did not have the strength to lift his legs up against gravity without assistance. He further stated the muscle tone of Resident A's arms was so bad that he was not able to use his hands. The physical therapist stated, "From what I read in Resident A's chart, he is incapacitated (deprived of strength or ability) in both the upper and lower extremities; a strength rating below  or [minus] means he only has twitching and no movement or strength to that body part."
A review of the significant change in status full comprehensive minimum data set (MDS, a comprehensive assessment tool used to formulate a plan of care for each resident), dated January 1, 2011 (Section G), showed Resident A had impaired range of motion on both sides to the upper extremities (shoulder, elbow, wrist, hand) and impaired range of motion on one side to the lower extremity (hip, knee, ankle, foot).
During an interview with CNA 2 on October 26, 2011 at 2:50 PM, she stated Resident A was assigned to her for care on October 10, 2011, on the day shift (7:00 AM to 3:00 PM). She indicated that Resident A was alert, but very contracted and stiff in the arms. She changed his incontinent (loss of bladder and bowel control) brief three times that shift. When asked, CNA 2 stated that Resident A had no skin breakdown in the groin or perineal (perineum) area (the area between the anus and the external genitalia), just mild dryness. She stated that she got Resident A up and sat him in a "Geri-chair" (a high backed cushioned recliner with a leg and foot rest). After lunch she checked him. He was slightly wet and she changed his brief again. She stated Resident A was rechecked again before change of shift at approximately 2:00 PM. She stated she reported off to (LVN 1) the licensed nurse that the resident was up in the chair and that she had changed him, but acknowledged that she did not give a verbal report to the next on-coming shift CNA. She stated that Resident A did not have the ability to extend his arms downward, that his arms and hands were drawn upward and stiff, and added, "The resident (Resident A) could not have injured himself that way." When asked, CNA 2 stated, she did not believe the scrotal injury was a result of any resident care equipment malfunction.
An Interview was conducted with CNA 3, on October 26, 2011, at 2:30 PM. She stated Resident A was contracted in the arms and required total assistance with all cares (such as bathing, personal hygiene, dressing, toileting/incontinence care, eating, transfers from bed to chair to bed/mobility).
An interview was conducted with CNA 4, on October 26, 2011 at 3:10 PM. She stated Resident A was much contracted in the arms and she stated Resident A had no wounds or open skin on the perineum or the buttocks areas.
During an interview with CNA 5 on October 26, 2011 at 3:30 PM, she stated she heard about the incident. She stated, "The CNA (CNA 6) assigned to Resident A (on October 10, 2011) at about 6:30 PM, went to move the resident from the Geri-chair back to bed, and changed his brief and found his skin torn, and that the resident had blood and feces in the diaper." She stated that Resident A had a habit of screaming out when handled. "He was scared when touched, and when handled he was tense and screamed out." When asked, she stated the residents were supposed to be checked and changed every two hours or as needed and that on day shift, the last brief change was usually by 2:00 PM.
On October 26, 2011 , record review of the Weekly Nurses Progress Summary notes dated September 29, 2011 and October 6, 2011, showed no documentation that indicated Resident A had any skin breakdown/problems to the scrotal area prior to October 10, 2011.
A review of the MDS assessments dated January 1, 2011, July 4, 2011 and October 10, 2011, showed no documented evidence that Resident A had skin ulcers or wounds present, prior to the October 10, 2011 incident. All three MDS assessments indicated that Resident A was always incontinent of bowel and bladder.
Resident A's MDS assessments dated January 1, 2011, July 4, 2011 and October 10, 2011, Section G, Transfers B, were all coded as a 3, to indicate Resident A required two+ persons physical assist with transfers.
The MDS assessment dated January 1, 2011, July 4, 2011 and October 10, 2011 also showed Resident A had total dependence on staff for activities of daily living (ADLs such as bathing, personal hygiene, dressing, toileting/incontinence care, eating, transfers from bed to chair to bed/mobility), which required full staff performance (assistance) every time, every day.
A review of the care plan titled "ADL Functional," dated December 26, 2010 and revised in March 2011, indicated Resident A required total assistance of 1-2 staff for all ADLs, which included toilet use (incontinence care) and personal hygiene. The interventions stipulated: * Reposition every two hours and as needed. * Check every two hours for soiling or wetness, thoroughly cleanse after each episode of incontinence.
On November 1, 2011 at 1:10 PM, an interview was conducted with CNA 6, who was assigned to Resident A and who reported the scrotal injury on October 10, 2011. He stated he arrived for duty October 10, 2011 at 3:00 PM, and received his resident care assignment at 3:40 PM. Resident A was assigned to him and he was also assigned dining room duties, which consisted of passing trays, help in feeding residents, and supervision of residents. CNA 6 went on to say that dining room duties also included the dining room clean up afterwards, and that this usually lasted from 4:30 PM to 5:45 PM. He stated, "I ran by the [resident] rooms and started fixing the linen cart. Around 6:30 PM, Resident A was up in the Geri-chair. I transferred him back (to bed) using the Hoyer lift." According to CNA 6, he transferred Resident A back to bed using the Hoyer lift and he was alone, even though Resident A's MDS assessments dated January 1, 2011, July 4, 2011 and October 10, 2011, Section G, Transfers B, were all coded as a 3, to indicate Resident A required two+ persons physical assist.
CNA 6 also stated that Resident A had a habit/behavior to scream out before he was even handled. He said, "I noticed brownish feces looking stuff mixed with blood to his left hand." He said he did not want Resident A's bed soiled so he quickly cleaned Resident A's hand, removed his shirt, and then his pants. CNA 6 noticed that the left side tab of Resident A's brief was slightly open. He removed the brief and there was bowel movement (BM) all over back to front. CNA 6 said he used a towel with warm water and soap and that he used "Big towels" to clean the resident (Resident A), due to the amount of stool. He stated, "I couldn't...didn't know how his scrotum looked at the time; I left the towel on his scrotum right between his legs; I turned him to the left side, got the lower end of the towel and wiped him down; I noticed the severe injury he had, and the skin was already off his scrotum. I stopped right there, left the rest of BM, and went to call the charge nurse (LVN 2)." CNA 6 stated the charge nurse assessed Resident A's injury and called the nursing supervisor, who assessed Resident A and called 911 for transport to the hospital.
Also during the interview, CNA 6 stated that the first time he "noticed" Resident A was at 4:30 PM, he was sitting in the [Geri] chair. At about 6:30 PM (4 to 5 hours had elapsed since the incontinence check by CNA 2 on the day shift) was the first time he checked Resident A. When asked what he (CNA 6) thought happened to Resident A, he stated he reported to work, but his resident care assignment was given to him late, he had fourteen to fifteen residents assigned to him, that Resident A was sitting in feces and urine, and then when he wiped [the scrotal area] with pressure, "Maybe the skin was already scratched off and he (CNA 6) made it worse." He said he did not notice the scrotal injury before wiping Resident A because there was stool around the area, and when he wiped with enough pressure to clean him, that is when he saw the skin tear to the area. CNA 6 stated Resident A had mobility to his left leg, but the right leg was fully contracted, and that the resident could move his arms and hands, but when he was touched he would stiffen up. "It's like he doesn't like to be touched. His hands are strong and he is able to push you away. I tell him to relax, that I just need to clean him up." CNA 6 stated the first time he took care of him, he asked another nurse to accompany him in Resident A's room. He stated Resident A's screams scared him and that the resident calmed down once the nursing cares were finished. He stated the behavior of screaming repeated each time care was rendered. When asked, CNA 6 said no other nurse was with him at the time of the incident.
An interview was conducted on October 26, 2011 at 4:00 PM, with Resident A's roommate (Resident B). Resident B stated that he was in his room watching television the day of the incident, and was waiting to see if CNA 6 was going to give him a shower. He said the CNA was first with Resident A. He stated that it sounded like Resident A was agitated when he was changed and began to yell/mumble, "No, no." The roommate stated, "I could see it in his face (CNA 6) that there's a situation; he (CNA 6) was going back and forth, back and forth. The resident (Resident A) always yells out, but with this guy he does it more. He (Resident A) mumbles, no ... no ... no." Resident B added, "CNA 6 is a big guy." The roommate was asked if he had ever witnessed any aggressive behavior from CNA 6, and he (the roommate) stated he could not directly see what was going on because of the way the room was situated.
An interview was conducted with the Administrator on October 26, 2011 at 6:00 PM to review the results of the facility's investigation report. She stated the conclusion of the investigation was that the resident mostly likely caused the injury to himself, when he was digging and scratching his scrotal area.
A review of the facility's policy and procedure titled, "Perineal Care," revised September
2005, indicated, "The purpose of these procedures is to provide cleanliness and
comfort to the resident, to prevent infections and skin irritation, and to observe the
resident's skin condition." The Perineal Care policy and procedure also indicated "the
following equipment and supplies will be necessary when performing this procedure:
4. Soap (or other authorized cleansing agent).
5. Personal protective equipment.
Steps in the procedure:
1. Place the equipment on the bedside stand. Arrange the supplies so they can be easily reached ...
10. For a male resident:
a. Wet washcloth and apply soap of skin cleansing agent.
b. Wash perineal area including the penis, scrotum, and inner thighs.
c. Thoroughly rinse perineal area in same order, using fresh water and clean washcloth.
d. Gently dry perineum following same sequence."
A review of the facility's job description policy for nursing assistant titled, "Job Description Nursing Assistant (CNA, RNA)" indicated the following:
"Job summary: Under the direct supervision of the charge nurse may be licensed vocational nurse or registered nurse (LVN, or RN), the CNA performs hands-on nursing care for the residents with emphasis on daily care needs, personal hygiene and cleanliness, grooming and skin care. The fundamental goal of the CNA is to promote the general well-being of residents assigned to him/her and to help conserve life, alleviate suffering, and promote health."
" ... 2. Personal Care
* Assists with, or performs personal hygiene for the resident, including washing the face, hand and all personal areas."
" ... 3. Lifting and Moving residents
* Repositions residents who cannot do so satisfactorily themselves, at least every two hours.
* Repositions residents who are up in the chair at least every two hours, e.g., assist to lie down or ambulate as instructed by the licensed nurse."
A telephone interview was conducted with the Director of Staff Development (DSD) on February 20, 2013 at 4:00 PM, for clarification of the facility's policy and practice protocols for perineal care services delivered to the residents. She stated that the CNA's (certified nursing assistants) were in-serviced (trained) and observed for adherence to the policy. She said big towels were not used in lieu of (instead of) washcloths for perineal care.
Therefore, the facility failed to ensure Resident A was provided with position changes and preventative skin care in accordance with the resident's needs when the facility staff failed to ensure that:
Resident A was repositioned every two hours in accordance with the facility policy and Resident A's plan of care on October 10, 2011 from 1:45 PM to 6:30 PM (a period of 4.5 hours).
Resident A was checked every two hours for incontinence and that Resident A received prompt, proper incontinence care in accordance with the facility policy and Resident A's plan of care.
The facility's failure resulted in a severe injury to Resident A's scrotum that required surgical intervention at an acute care hospital, which caused Resident A pain, bleeding and put Resident A at risk for complications including infection and sepsis (infection in the bloodstream or body tissues).
This violation had a direct relationship to the health, safety, or security of the resident.