| 4278 |
SOUTHWELL HEALTH AND REHABILITATION |
115655 |
260 MJ TAYLOR ROAD |
ADEL |
GA |
31620 |
2016-07-01 |
282 |
E |
0 |
1 |
0GTS11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined that the facility failed to ensure that blood sugar levels were obtained and/or insulin administered as care planned for five residents (#99, #84, #23, #104 and #38), failed to provide wound treatment as care planned for one (1) resident (#64) from a total sample of forty-two (42) residents. Findings include: 1. Resident #99 had a care plan problem in place since 12/22/15 for having a potential for altered nutrition with an intervention for licensed nursing staff to obtain blood sugar levels (Accucheck/Finger Stick Blood Sugar-FSBS) as ordered and administered insulin based on a sliding scale as indicated. However, a review of the clinical record revealed that licensed staff did not administer the correct amount of insulin on 4/10/16 at the scheduled time of 4 p.m Cross reference to F309. 2. Resident #84 had a care plan intervention since 8/24/15 for nursing staff to obtain blood sugar levels as ordered. There was a physician's orders [REDACTED]. However, a review of the clinical record revealed that licensed nursing staff did not document the blood sugar level results twice in (MONTH) (YEAR) (4/15/16 and 4/23/16) and once in (MONTH) (YEAR) (5/13/16). Cross reference to F514 3. Resident #104 was originally admitted to the facility on [DATE], discharged for one day 05/20/16 and re-admitted on [DATE]. The resident had a [DIAGNOSES REDACTED]. Review of the comprehensive care plan problem to address the resident's Diabetes Mellitus included and intervention for Accucheck/Finger Stick Blood Sugar (FSBS) before meals and at bedtime with sliding scale insulin coverage as indicated. Review of the medical record for this resident revealed a physician's orders [REDACTED]. If less than 60 follow hypoglycemic protocol, FSBS results 61-140 give 0 units, FSBS results 141-180 give 1 units, FSBS results 181-240 give 2 units, FSBS results 241-300 give 4 units, FSBS results 301-400 give 6 units and if greater than 400 give 8 units and call the physician. Review of the (MONTH) (YEAR) Medication Administration Record [REDACTED]. m. FSBS was 310, 4 units sliding scale insulin given, per sliding scale order resident should have been 6 units. Review of the (MONTH) 2106 MAR indicated [REDACTED]. m. FSBS was 181, 1 unit sliding scale insulin, per sliding scale insulin order the resident should have received 2 units. Cross refer to F309 4. Resident #38 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. Review of the comprehensive care plan revealed interventions that included Accucheck/Finger Stick Blood Sugar (FSBS) before meals and at bedtime with sliding scale insulin coverage as indicated. review of the resident's medical record revealed [REDACTED]. Review of the MAR for (MONTH) (YEAR) revealed that on 03/01/16 at 4:00 p.m. the resident had a FSBS of 154, no sliding scale insulin given, per sliding scale order resident should have received 1 unit. Review of the (MONTH) (YEAR) MAR indicated [REDACTED]. Review of the (MONTH) (YEAR) MAR indicated [REDACTED]. Cross refer to F309 5. Review of resident #64's Plan of Care dated 3/9/16 revealed a problem to address the resident's impaired skin integrity due to a stage four (4) pressure ulcer to the sacrum which included an intervention for treatments to be done as ordered. A medical record review revealed a physician's orders [REDACTED]. Review of the Treatment Record for (MONTH) (YEAR) revealed the licensed nursing staff documented the wound care to be provided once a day on 3/24, 3/25, 3/28, 3/29, 3/30 and 3/31/16 and not as ordered by the physician. An interview on 6/30/16 at 1:00 p.m with the Director of Nursing (DON) revealed the nurses failed to follow the Plan of Care for the problem identified as Skin Integrity Impaired with an intervention to administer treatments as ordered. Cross Refer to F314 6. Review of resident #23's Quarterly MDS assessment dated [DATE] revealed section I [DIAGNOSES REDACTED]. Review of resident #23's Plan of Care dated 10/27/15 with a reviewed date of 5/4/16 revealed a problem to address the resident's Altered Nutrition Fluid Volume Imbalance related to effects of requiring therapeutic diet due to disease processes, not consuming all meals and nutritional supplements offered, requiring [MEDICAL TREATMENT] and having fluctuations in blood sugar. The interventions included for licensed nursing staff to administer Insulin as ordered. A review of the April, (MONTH) and (MONTH) (YEAR) physician's orders [REDACTED]. However, Review of the Medication Administration Record [REDACTED]. April: 4/3/16, 4/8/16, 4/9/16, 4/12/16, 4/13/16, 4/14/16, 4/15/16, 4/19/16, 4/20/16, 4/22/16, 4/23/16, 4/24/16, 4/25/16, 4/27/16 and 4/29/16 May: 5/2/16, 5/3/16, 5/6/16, 5/16/16, 5/17/16, 5/20/16, 5/21/16, 5/24/16, 5/30/16 and 5/31/16. June: 6/1/16, 6/3/16, 6/4/16, 6/5/16 ,6/6/16, 6/7/16,6/8/16, 6/9/16 ,6/10/16, 6/11/16, 6/15/16, 6/17/16, 6/19/16, 6/20/16 and 6/22/16. During an interview on 6/30/16 at 11:45 a.m. with the Director of Nurses (DON), the DON confirmed the Plan of Care was not followed for the Problem identified related to Altered Nutrition/ Fluid Imbalance related to having fluctuation in blood sugars with the intervention insulin as ordered. Cross refer to F309 |
2020-01-01 |