cms_GA: 10428
Data source: Big Local News · About: big-local-datasette
rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
10428 | LAKE CROSSING HEALTH CENTER | 115424 | 6698 WASHINGTON ROAD | APPLING | GA | 30802 | 2009-10-21 | 328 | D | 0 | 1 | P8VR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure that residents receiving oxygen therapy had oxygen saturation levels performed as ordered by the physician for four (4) residents #10, 13, 14, & 15 from nineteen (19) sampled residents. Findings include: Record review revealed that resident #10 had [DIAGNOSES REDACTED]. The resident also had September 2009 and October 2009 physician's orders [REDACTED]. Review of the September 2009 Medication Administration Record (MAR) revealed that this was not done. Within the first nineteen days in October 2009 these levels should have been measured and recorded thirty eight times. Review of the Medication Administration Record (MAR) for October 2009 on 10/20/09 revealed that these levels were measured on 10/17 twice, 10/18 once, and 10/19 twice, a total of five (5) of the thirty eight times expected. In an interview on 10/20/09 at 12:15 p.m., the Assistant Director of Nurses (ADON) confirmed that oxygen saturation levels are only recorded on the MAR and could offer no explanation about why these levels were not being done as ordered. Record review revealed that resident #14 was hospitalized in July 2009 with [DIAGNOSES REDACTED]. The resident was readmitted to the facility on [DATE] with orders to measure the oxygen saturation level twice a day. Review of the August 2009 and September 2009 MAR's revealed that saturation levels were not done. Review of the October 2009 MAR on 10/21/09 revealed that oxygen saturation levels was done on 10/18 once, 10/19 & 10/20 twice. In an interview on 10/21/09 at 8:00 a.m. the ADON acknowledged that these levels were not done as ordered and that further facility review was needed to address this problem. She added, that the admission orders [REDACTED]. Review of the clinical record for resident #13 revealed monthly physician's orders [REDACTED]. Review of the Medication Administration Record (MAR) for 9/09 revealed oxygen saturation were not measured on any days of this month. Review of the MAR for 10/09 revealed that oxygen saturation were not measured for eleven (11) of thirty-nine (39) opportunities. Interview with the Director of Nursing on 10/20/09 at 2:55 p.m. confirmed that staff had not measured the oxygen saturation levels as ordered. Review of the clinical record of resident #15 revealed the resident had a [DIAGNOSES REDACTED]. Review of August 2009 and September 2009 physician's orders [REDACTED]. Review of the August 2009 and September 2009 Medication Administration Records (MAR) revealed the oxygen saturation levels were not measured on 08/01/09, 08/02/09, 09/06/09 and 09/08/09. During an interview on 10/20/09 at 3:00 p.m. with Licensed Practical Nurse (LPN) "KK" she confirmed that the oxygen saturation levels were not done as ordered. | 2014-07-01 |