cms_GA: 10582
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 |
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10582 | NEW LONDON HEALTH CENTER | 115771 | 2020 MCGEE ROAD | SNELLVILLE | GA | 30078 | 2009-09-24 | 314 | D | W1TL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interviews, it was determined that for three (3) of the twenty-four (24) sampled residents, #1, #6 and #19, the facility failed to prevent pressure ulcers from forming for residents not previously having pressure ulcers and failed to treat pressure ulcers appropriately to promote healing and prevent new ulcers from forming. Findings include: Review of the clinical record for resident #1 revealed a Minimum Data Set ((MDS) dated [DATE] that indicated the resident had intact skin, with no breakdown. Section M5 of this document also indicated that staff was not using any protective or preventive skin care. However, review of the Master Care Plan revealed that the resident was assessed as being at risk for pressure ulcers. A progress note by the Nurse Practitioner and attending physician, dated 09/17/09 described a Stage II ulcer behind her left ear. Observation of this pressure ulcer on 09/22/09 at 2:15 a.m. revealed that the resident was wearing eye glasses and had plastic tubing around her ears for receiving supplemental oxygen. There was also a dressing in place behind her left ear. Interview with the Director of Nurses on 09/23/09 at 7:45 a.m. indicated that she was unaware of any preventive measures that had been put into place to prevent this pressure ulcer from forming. Record review for resident #6 revealed the resident a care plan dated 12/31/08 that indicated the resident had a potential for skin breakdown. A Nurse's Note dated 9/11/09 indicated the resident had received a skin shear to the right buttock. This was described as a Stage II pressure area measuring 0.2 centimeter in diameter. The Treatment Record for September 2009 described this Stage II wound on the right buttock as a skin shear. During an observation of the resident receiving incontinent care on 9/22/09 at 2:30 p.m., the Stage II pressure sore on the right buttock was not covered by a dressing, but the skin was intact. The resident's left buttock was observed with one (1) reddened open area and one (1) closed reddened area. In an interview with Certified Nursing Assistant (CNA) "NN" at the time of this observation, she stated that she did not know about the dressing on the right buttock and she thought the open area on the left buttock was there when she changed the resident earlier. CNA "MM" stated that she was not aware of the open areas on the left buttock, nor any skin impairment on the right buttock. During a second observation of the resident on 9/23/09 at 9:50 a.m. with Treatment Nurses "RR" and "ZZ", both nurses stated that they had not been made aware of the two new areas on the left buttock. One area was red and open during this observation. LPN "ZZ" described the open area as a skin shear which would be a Stage II wound. They both indicated that the CNA's should have notified them or the Unit Manager of any changes in the resident's skin. In an interview with the Unit Manager on 9/23/09 at 10:10 a.m., she stated that CNA's "NN" and "MM" had not notified her of any new areas of skin breakdown or that the pressure sore dressing was not in place on the right buttock. Review of the facility's policy on the Prevention of Pressure Ulcers revealed that staff were directed to avoid friction and skin shears by using appropriate lift techniques rather than dragging when repositioning. Record review revealed that resident #19 had Stage II pressure sores on the right hip and left ischium. Review of current physician's orders [REDACTED]. During an observation of incontinent care for resident #19, on 9/23/09 at 3:10 p.m. with Certified Nursing Assistants (CNA) "DD" and "EE", there were no dressings on the pressure sores. Observation of the resident's pressure sores later that day at 3:25 p.m. with Licensed Practical Nurse (LPN) "ZZ" revealed that these wounds still did not have a dressing. She further indicated that she had not been advised that the dressings were not in place. An interview with LPN "ZZ" on 9/24/09 at 4:00 p.m. revealed she had no explanation as to why the dressings were not in place on the previous day or why the CNA's had not notified her. | 2014-04-01 |