cms_GA: 10570
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 |
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
10570 | PRUITTHEALTH - GREENVILLE | 115658 | 99 HILLHAVEN RD. | GREENVILLE | GA | 30222 | 2009-08-05 | 514 | E | DOSV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews and record reviews, the facility failed to ensure that physician's progress notes were in the resident's medical record for ten (10) residents (#3, #4, #6, #7, #8, #9, #10, #15, #16, and #20) and that physician's orders [REDACTED]. Findings include: 1. Record reviews for residents #3,#4, #6, #7, #8, #9, #10, #15, #16, and #20 revealed missing physician's progress notes. Interview on 8/4/09 at 3:40 pm with the physician revealed that there has been a problem with progress notes missing from resident's medical records. The physician indicated that she brings her progress notes and facility staff is suppose to place the notes in the residents' records. She further indicated that she has had problems with missing progress notes since October 2008. Interview of 8/5/09 at 9:45 am with the Director of Health Services revealed that the physician's progress notes were missing from resident's medical records. She further revealed that the physician's visits at least once a week but there are no progress notes and that medical records staff are responsible for placing progress notes in the records. 2. Record review for resident # 1 revealed that a [MEDICATION NAME] order written on 7/26/09 by a nurse indicated an "increase" in the [MEDICATION NAME] dose to 100mgs. three times a day (t.i.d.). Further record review revealed that on 7/23/09 the [MEDICATION NAME] was ordered 100mgs every six hours (q6h), which is four times a day. The order on 7/26/09 did not reflect an "increase" Review of the July 2009 MAR for resident #1 revealed that [MEDICATION NAME] is written as " [MEDICATION NAME] 4mls (100mgs) per tube q6h t.i.d. with hours of administration as 9am, 3pm, and 9pm. Every six hours (q6h) is not the same as t.i.d. During post survey review of the June 2009 MAR for resident #1 revealed that [MEDICATION NAME] two (2) capsules via tube twice a day (b.i.d) had been marked through and [MEDICATION NAME] 125 mgs/5mls. suspension 4 ml (100mgs) per tube q6h had been written in the same block under the [MEDICATION NAME] capsules. The hours of administration were 9am and 9pm from 6/1- 6/30/09. This does not reflect clear and concise documentation of the dose and frequency of the [MEDICATION NAME]. | 2014-04-01 |