cms_GA: 429
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 |
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
429 | MITCHELL COUNTY NURSING HOMES | 115266 | 37 SOUTH ELLIS STREET | CAMILLA | GA | 31730 | 2017-09-21 | 314 | D | 0 | 1 | P90P11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, the facility failed to follow orders for the wound care dressing change and failed to use infection control technique for one resident, Resident (R) #32, out of 32 sample residents. Findings include: Unit 2: Review of medical record for R#32 revealed wound care orders as, remove old bandage from heel, cleanse with normal saline, apply no sting barrier, apply Activoat and calcium alginate and wrap with [MEDICATION NAME] three times a week on Monday, Wednesday and Friday and as needed. During an observation of wound care on 9/20/17 at 9:30 a.m., Liscensed Practical Nurse (LPN) AA failed to adequately prepare for the dressing change and did not have three of the ordered wound care items available on the field. Wound care orders were as follows for right heel, cleanse with normal saline, apply sting barrier, apply [MEDICATION NAME] and calcium alginate and wrap with [MEDICATION NAME] three times a week on Monday, Wednesday and Fridays and as needed. LPN AA did not have the [MEDICATION NAME], the calcium alginate and the [MEDICATION NAME] on the field. Observation of wound care on R#32 on 9/20/17 at 11:30 a.m. by LPN AA Wound Care Nurse with assistance of Registered Nurse (RN) BB. LPN AA removed dressing and disposed of properly. Hands were sanitized and nurse donned gloves, area on heel was measured and cleaned and photographed. Hands were sanitized and nurse donned gloves, nurse opened package of skin barrier and applied around wound, reached over and opened drawer on dressing cart, reached inside and took out a packet of [MEDICATION NAME]. She then opened the package and removed contents, folded the dressing and placed over wound. While holding in place with one hand, nurse opened dressing cart drawer again and took out 4 x 4s and placed over dressing. She then opened dressing cart drawer again and reached in and took out roll of [MEDICATION NAME] and wrapped foot. She again opened the dressing cart drawer and took out a pad of dressing strips and placed over [MEDICATION NAME] to hold [MEDICATION NAME] in place. Nurse removed gloves and sanitized hands. it was noted that nurse failed to place calcium alginate over wound during dressing change as ordered. Interview with LPN AA on 9/20/17 at 11:45 a.m. revealed she realized that she had not removed all the supplies from the dressing cart only after she started dressing change and had to open the cart and remove them. She stated she didn't realize that she had put her goved hand in the drawer until she had finished the dressing change. LPN AA did not realize that she had missed putting calcium alginate on the wound as ordered. Interview with RN BB on 9/20/17 at 11:55 a.m. revealed that she was the nurse that taught LPN AA protocols for wound care and that she should not have reached back into the cart with dirty gloves to remove items. Discussed with RN BB that nurse failed to put calcium alginate on wound as ordered. She stated she would change the dressing and correct the error. Interview with Assistant Director or Nursing (ADON) on 9/20/17 at 1:20 p.m. revealed that her expectations of the wound care nurses is that they provide the care as ordered and use appropriate infection cpntrol techniques. When asked about training for wound care nurses and review of their training she stated that if the infections of wounds start to trend upward then she will look at what is going on with the wound care. She stated if a resident's wound is getting worse she will look to see what the issue is and they will discuss at weekly wound meetings. Discussed observation of wound care for resident. ADON stated that the wound care nurses are taught to get everything they need out ahead of time and organized so they don't have to stop and get something they forgot. She stated that going back into the drawer with a gloved hand that had been touching the skin or wound was not acceptable. | 2020-09-01 |