cms_GA: 2688
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 2688 | PINEWOOD MANOR NURSING HOME & REHABILITATION CNTR | 115586 | 277 COMMERCE STREET | HAWKINSVILLE | GA | 31036 | 2019-11-07 | 689 | D | 1 | 0 | 1NRG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews and record review, the facility failed to ensure that an accident, that occurred during a transfer and resulted in injury, was reported timely to prevent a delay in care for one of three residents (R#1) reviewed for accidents. Findings include: Resident (R) #1 had [DIAGNOSES REDACTED]. A care plan, dated 5/5/19, documented that R#1 was bed and chair bound and required physical assistance with bed mobility, transfers and locomotion. The care plan also included that a Geri-chair was utilized for comfort and positioning. A review of the clinical record revealed that a change in condition was identified on 7/29/19. An untimed 7/29/19 nurse's note documented that R#1's family thought the resident had a sprained left lower extremity. The Physician was notified, and orders were received to obtain x-rays of the bilateral lower extremities due to swelling, to rule out fracture. A review of the x-ray results revealed fractures to the left lateral cortex of the fibula and anterior cortex of the distal tibia. A walker boot was ordered applied to the left lower extremity. The resident's transfer status was also changed to be completed via a mechanical lift. Record review revealed a Physician order [REDACTED]. Review of a Radiology report dated 7/29/19 documented: a subtle medial malleolus fracture is suspected. Review of a Radiology report dated 7/30/19 documented: Non displaced [MEDICAL CONDITION] cortex of the fibula, questionable [MEDICAL CONDITION] cortex of the distal tibia. The facility initiated an investigation into the cause of the left lower extremity fractures. A subsequent 7/29/19 7:45 a.m. nurses note, completed by the Director of Nursing (DON), documented: she was made aware of the origin of the injury by a staff member on 7/29/19. On the Thursday prior to 7/29/19 (which would have been 7/25/19), when the resident was being transferred from the bed to the Geri-chair, her foot had become lodged between the bottom of the chair. Record review revealed a handwritten statement signed by CNA AA that documented the following: I CNA AA was caring for R#1 after preparing her clothes and under garments I began to transfer R#1 from the bed to the Geri-chair. While transferring R#1 to the Geri-chair her foot had gotten caught between the bottom part of the chair that folds. (sic) Record review revealed that R#1 had an order in place since 10/5/18 for two 325 milligram (mg) [MEDICATION NAME] tablets every six hours as needed for pain and an order in place since 10/8/18 for [MEDICATION NAME] 50 mg every six hours as needed for pain. However, review of the (MONTH) 2019 Medication Administration Record [REDACTED]. After the incident on 7/25/19 review of the (MONTH) 2019 MAR indicated [REDACTED]. During interviews on 11/7/19 at 12:45 p.m. and 3:50 p.m., the DON stated that R#1 was being transferred correctly by Certified Nursing Assistant (CNA) AA on 7/25/19 when her foot was caught under the Geri-chair. The DON stated that CNA AA did not report the incident of the resident's left foot getting caught under the chair on 7/25/19, when the incident occurred. The DON confirmed that CNA AA should have reported the incident on 7/25/19. | 2020-09-01 |