cms_GA: 2680
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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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2680 | PINEWOOD MANOR NURSING HOME & REHABILITATION CNTR | 115586 | 277 COMMERCE STREET | HAWKINSVILLE | GA | 31036 | 2017-09-21 | 325 | D | 0 | 1 | V4Q111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, staff interview and facility policy review it was determined the facility failed to implement physician orders [REDACTED].#71) out of two residents reviewed for weight loss. The sample size was 31 residents. Findings include: Medical record review of R#71's Face Sheet revealed the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. On 9/19/17 at 8:52 a.m., R#71 was observed upright in bed. At the time, the resident acknowledged she had a percutaneous endoscopic gastrostomy (PEG tube) (used to instill nutritional feedings and medications into the stomach). She said she no longer received feedings in the tube, but required daily dressing changes. According to the resident's medical record Minimum Data Set (MDS) admission assessment (a comprehensive resident assessment) dated 6/7/17, the resident's weight was 154 pounds (lbs.) on admission. R#71's medical record Nutritional Documentation dated 7/27/17 revealed the resident received feedings in her feeding tube prior to the discontinuation of the feedings on 8/05/17. R#71's medical record Nurse's Notes dated 8/5/17, indicated the resident was eating food and refusing her tube feedings, and indicated new orders were received allowing the resident to continue to take food in by mouth. The resident's medical record (MONTH) (YEAR) physician's orders [REDACTED]. According to the medical record Nutritional Documentation documented by the Consultant Dietitian (CD), R#71 had a 14-lb. weight loss in 90 days, which was 11.7% loss and an 8-lb. weight loss, which was 5.5% in 30 days. R#71's weight on 8/31/17, documented in the resident's medical record Weight Record was 136 lbs. and on 9/19/17 it was 137 lbs. The CD's medical record Nutritional Documentation note dated 8/31/17, contained her recommendation for one can of Ensure (a nutritional supplement) .bolus one can if she eats less than 50% of a meal. According to R#71's medial record physician's orders [REDACTED]. During a medical record review of R#71's (MONTH) (YEAR) Personal Care Record documentation indicated the resident ate poorly, noted as 25% in the document legend, at least nine days. A review of R#71's medical record current Medication Administration Record [REDACTED]. During an interview with Licensed Practical Nurse (LPN) AA, on 9/21/2017 at 8:15 a.m., regarding the lack of documentation on R#71's MAR indicated [REDACTED]. The LPN confirmed no Ensure had been given on the days the resident had a documented less than 50% meal intake. She said sometimes people bring food in for R#71. LPN AA was asked if she knew for sure or had documentation to confirm that the resident received an outside meal and the percentage of meal intake, on the days identified with less than a 50% intake, for (MONTH) (YEAR). LPN AA said she did not. She confirmed there was no documentation to indicate the resident ate outside food. Medical record review of R#71's (MONTH) Nursing Notes revealed notes dated 9/17/17 and 9/20/17. Neither of the two notes documented R#71's intake of facility or outside food. An interview with the facility's CD on 9/20/17 at 3:27 p.m., revealed she reviewed weights every month when she visited the facility. She said the dietary manager cannot get the weights done within the 10 days because she is doing them herself. The dietitian indicated the weights were consequently not obtained around the same time each month. During the phone interview, the dietitian could not speak specifically regarding R#71, since she did not have the resident's specific information available. The facility provided two policies related to weight loss. The facility's policies titled Policy on Resident Weights, undated, and Physician Notification of Significant Weight Loss Policy & Procedure, also undated, contained no interventions or procedures for re-weights or monitoring for implementation of interventions or physician orders [REDACTED]. Both polices focused on the staff designated to obtain the weights and the providers to be notified of the loss. | 2020-09-01 |