cms_GA: 2934
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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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 2934 | WARNER ROBINS REHABILITATION CENTER | 115612 | 1601 ELBERTA ROAD | WARNER ROBINS | GA | 31088 | 2017-10-26 | 315 | D | 1 | 1 | 9WJL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on closed record review, interview, and review of facility policy, it was determined the facility failed to ensure two Residents (R)#26 and (R)#129 from a sampled 34 residents with a catheter received the appropriate care and services to prevent infection and trauma. The findings include: 1. Review of a facility document titled Suprapubic Catheter revised 5/23/17 documents the purpose is to provide proper care of the catheter site to reduce skin irritation and and/or infection. The document indicates the care procedure and documentation of care in the treatment record. Closed record review revealed R#26 was admitted to the facility 4/10/17 with [DIAGNOSES REDACTED]. A review of the resident's quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident was assessed with [REDACTED]. The resident was coded as requiring total assistance with bed mobility, transfer, and activities of daily living; continent of bowel and using a suprapubic catheter; and fall history. Review of the resident's catheter care plan with a revision date of 6/4/17 indicates the resident was at risk for UTIs related to the suprapubic catheter. Interventions include observe for pain/discomfort due to catheter; encourage fluids by mouth; change suprapubic catheter monthly; position catheter drainage bag and tubing below the level of the bladder; check tubing for kinks during rounds and as necessary; suprapubic catheter care as ordered; treatment to catheter are ordered; and leg strap on catheter tubing to promote proper drainage. Review of physician orders dated 4/23/17 revealed the following; - monitor suprapubic catheter site every shift for signs of infection - position drainage bag and tubing below the level of the resident's bladder - catheter care every shift with warm water and soap - encourage extra fluids every shift to prevent risk of infection - leg strap on always to promote drainage - change suprapubic catheter monthly and as needed. Review of physician orders dated 5/9/17 revealed the resident was to receive Xeroform dry dressing every day to the suprapubic catheter site. A review of the treatment administration records (TAR) for the month of (MONTH) (YEAR) revealed the staff failed to document 13 days that the resident received the Xeroform gauze dressing to the suprapubic catheter site. Also, the staff failed to document nine days that the resident received catheter site care. The (MONTH) (YEAR) TAR sheets show the facility failed to document the resident receiving catheter care, the presence of the catheter strap and the position of the draining bag on 22 shifts. The (MONTH) (YEAR) TAR sheets show the facility staff failed to document the resident receiving catheter care, the presence of the catheter strap and the position of the draining bag on 28 shifts. A review of the nurses' notes dated 8/4/17 revealed the resident was started on Keflex 250 milligrams for UTI. An additional review nurses note dated 8/8/17 documents the resident had redness with no drainage around the suprapubic site. Continued review of nurses' notes dated 10/8/17 documents the resident continues antibiotic therapy for an infected suprapubic catheter; site is slightly red no drainage swelling or odor noted. Interview on 10/23/17 at 7:30 p.m. with R#26's family member revealed the family had concerns about the resident's care especially the resident's suprapubic catheter. The family stated resident had developed a urinary tract infection due to the staff's failure to care for the catheter properly. The family member stated there were times when visiting the resident suprapubic catheter site did not have a dressing covering it. An interview with the Director of Nursing (DON) on 10/25/17 at 3:30 p.m. on the West Hall revealed the facility utilized agency nurses during this period time and it was identified there was problem with the staff documenting treatments appropriately. An interview with Licensed Practical Nurse (LPN) OO on 10/26/17 at 1:30 p.m. on the West Hall nurses station revealed she had provided care to R#26 on 10/21 and 10/22; however, she did not perform the catheter site care becThe facility failed to ensure R#26 received the appropriate treatment for [REDACTED]. ause the resident had just returned from the hospital on [DATE] and the treatment was not re-ordered. The LPN further stated that she did not contact the MD about re-ordering the suprapubic catheter treatments. 2. Review of the facility policy titled Indwelling Catheter Care (SHCRC .06) revised 5/23/17 noted the following: Procedure: 12. Provide enough slack before securing catheter to prevent tension on tubing. Use Velcro strap to secure tubing to the thigh. Resident # 129 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set ((MDS) dated [DATE] revealed R#129 had a Brief Interview for Mental Status (BIMs) score of 14, indicating the resident was cognitively intact. R#129 required extensive assistance with bed mobility, transfer, locomotion on and off the unit, dressing, toileting, and personal hygiene. The resident had no impairment to the upper extremities but had impairment bilaterally to the lower extremities. The resident had an indwelling catheter for bladder function and was always incontinent of bowel. Review of R#129's care plan revised on 3/14/17 revealed the resident was At risk for recurrent urinary tract Infections (UTIs) related to use of Foley catheter and history of urosepsis prior to admission. Diagnosis: [REDACTED]. The goal revised on 10/25/17 noted the resident will be free from catheter related trauma through the review date. Interventions included Secure Foley catheter with strap to leg.: An interview conducted on 10/25/17 with Certified Nursing Assistant (CNA) EE revealed that she gives R#129 a bed bath and provides catheter care. She revealed that the resident gets out of bed with a Hoyer lift and the assistance of two staff members. During an observation of wound care on 10/25/17 at 4:03 p.m. R#129's Foley catheter was noted to be unsecured. There was no leg strap present and the tubing was not fastened to the sheets in a manner to prevent tension on the resident's catheter. During the observation, an interview was conducted with Registered Nurse (RN) A[NAME] AA, confirmed the Foley catheter should have been secured with a leg strap. An observation conducted on 10/26/17 at 9:46 a.m. revealed R#129's Foley catheter remained unsecured with a leg strap or other device. An interview conducted at 9:50 a.m. with certified nursing assistant (CNA) GG revealed that she did not know if R#129 should have a leg strap for his catheter. GG stated that most of the residents' catheters were secured by a leg strap. | 2020-09-01 |