cms_GA: 152
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 152 | HABERSHAM HOME | 115099 | HIGHWAY 441 NORTH, BOX 37 | DEMOREST | GA | 30535 | 2018-04-18 | 610 | D | 1 | 0 | Inf | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review, review of facility policy, staff interviews and family interview the facility failed to investigate an injury of unknown origin related to a burned area on the upper left chest of Resident #1 (R#1). The sample was four (4) residents. The facility census was seventy-seven (77). Findings include: Review of Abuse Prohibition Policy and Procedure effective date 12/20/17- Investigation of injuries of unknown source. Interviews will also be conducted when a resident has an injury from an unknown source. Signed statements will be gathered from : Staff who cared for resident just prior to and just after injury; Other reliable residents in the vicinity nearby area; Family or visitors who may have noticed anything. Once an injury of unknown source has been identified, staff will observe resident and watch behavior to see if the source of injury can be identified based on the resident's behavior (i.e. how they move their arms, walk, push a wheelchair, behave, etc.) The chart will be reviewed for any pertinent information that could help the investigation. If the abuse resulted in an injury, the facility will report to appropriate agencies no later than 2 hours after the allegation is made. Record review for R#1 revealed admission to the facility on [DATE], with [DIAGNOSES REDACTED]. During an observation conducted on 4/18/18 at 10:25 a.m. of R#1 an area of burned, discolored skin was noted on her left upper chest. She was sitting in the dining room for activities and her shirt was positioned slightly away from her left upper chest. The area was one inch long and three quarters inch wide with 2 small pink superficial open areas. The area was clean, dry, without drainage or redness. R#1 did not show any signs of discomfort. R#1 was confused and did not express herself clearly and could not explain anything about this burned area. Review of Nurse's Notes dated 4/14/18, time 20:35, revealed as follows: Resident noted to have an old burn mark in the shape of a curling iron on her left collar bone area. At least 3 days old it is beginning to peel off in areas. Resident is unable to say how it happened and expresses no c/o pain or (sic) from it. Resident's responsible party present and aware. Nurses notes revealed the Physician was notified of findings on 4/15/18 at 7:31. An Incident Report dated 4/15/28, time 8:14 revealed the same Nursing documentation as the above Nurse's Note. On 4/18/18 at 2:40 p.m. an interview with the Quality Assurance and Compliance Nurse revealed the burn to R#1's left upper chest had not been reported or investigated. The Quality Assurance and Compliance Nurse had reviewed the Incident Report and Nurse's Note from 4/14/18 and 4/15/18 and thought the family had been using a curling iron on R#1's hair and dropped it on her chest. The Quality Assurance and Compliance Nurse confirmed that after reading these documents again, that is not what the documentation indicates. The Quality Assurance and Compliance Nurse verified she should have investigated this incident, and reported it within two (2) hours of it's discovery. A family member of R#1 was interviewed on 4/18/18 at 3:55 p.m. The family member revealed she had discovered the burn on the left upper chest of R#1 on 4/14/18 at approximately 7:30 p.m. and had no idea how she was burned. The family member indicated neither she or any other family or visitors that she knew of had been using a curling iron or anything else that would produce a burn on R#1. The family member had reported the burn to the Nurse on duty and the Nurse and CNA had not known anything about it either. An interview on 4/18/18 at 4:48 p.m. with the Director of Nurses (DON) revealed she had called the beautician on 4/18/18 at 4:30 pm and the beautician had not seen R#1. The DON revealed the Quality Assurance Committee and the Department Heads look at all incident reports in the morning meeting every week day. The Incident Report and Nursing documentation had been reviewed for the burn to R#1's chest and no one was questioned about the incident. No investigation occurred and the incident had not been reported to the State. The DON confirmed the Nursing documentation and incident report had been misinterpreted and everyone had thought the family had caused the burn with a curling iron. The DON verified that the documentation does not really indicate this and she had interviewed the family this afternoon and knows they did not burn the resident, and they do not know how the resident was burned. They DON acknowledged this was an injury of unknown origin and should have been reported within two (2) hours and then should have been investigated. | 2020-09-01 |