| 5291 |
WILLOWWOOD NURSING CENTER |
115327 |
4595 CANTRELL ROAD |
FLOWERY BRANCH |
GA |
30542 |
2015-07-31 |
309 |
D |
0 |
1 |
OBW211 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and staff interviews the facility failed to ensure physicians orders related to diet, Ted hose, and medication consistency were followed for three (3) residents (#H, #80, and #103) from a sample of thirty one (31) residents. Findings include: 2. Review of Physician orders [REDACTED].) Observation of resident #80 on 07/27/15 at 3:05 p.m. revealed the resident was wearing regular socks and shoes. Further observations on 07/28/15 at 9:30 a.m., 07/28/15 at 2:30 p.m., 07/29/15 at 11:00 a.m., 07/29/15 at 3:05 p.m., 07/30/15 at 1:40 p.m. revealed that the resident was always wearing regular socks and shoes. Review of the Medication Administration Record [REDACTED]. From 07/27/15 to 07/29/15 documentation indicated Ted hose were in place AM, and removed at HS. Further review of the care plan indicated feet could be elevated for [MEDICAL CONDITION]. No mention of Ted hose. Interview with the Licensed Practical Nurse (LPN) MM on 07/30/15 at 3:09 p.m. confirmed the resident was not wearing Ted hose. MM was not aware they had not been put on the resident's legs for the past four (4) days. Interview with the Certified Nursing Assistant (CNA) on 07/30/15 at 3:12 p.m. revealed she was not aware the resident was supposed to have Ted Hose. Review of the Activity of Daily Living (ADL) work sheets indicated a general statement of how the resident dressed, putting on, taking off clothing, including Ted Hose if applicable. 3. Review of the medical record for resident #103 indicated a Pharmacy recommendation on 05/15/15 to clarify route of [MEDICATION NAME]. All other medications were per feeding tube, but the [MEDICATION NAME] was listed by mouth (PO). The pharmacist had recommended a [MEDICATION NAME] solution. On 05/20/15 the physician agreed with the pharmacist and ordered [MEDICATION NAME] by solution. As of 07/31/15 the resident was still receiving [MEDICATION NAME] sprinkles through her feeding tube. Interview with the Assistant Director of Nursing (ADON) on 07/31/15 at 2:00 p.m. revealed she was not sure why the order was missed and had not been changed. 1. A record review for resident H revealed an admission date of [DATE] with diagnoses, but not limited to, Diabetes Type II and End Stage [MEDICAL CONDITION]. A review of the Annual assessment dated [DATE] Minimum Data Set (MDS) assessment Section K- Swallowing/Nutritional Status indicated the resident was receiving a therapeutic diet. A review of the Care Plan dated 05/21/15 identified weight fluctuation and fluid imbalance with interventions that included, but not limited to, Diet as ordered per physician. A review of the Diet Requisition dated 06/1/15 request: Discontinue the Renal, NAS (No added salt,) NCS (No concentrated sweets) Diet. New Diet Regular NAS and a review of the Physician order [REDACTED]. A review of the Physician order [REDACTED]. An interview conducted on 07/29/15 at 12:43 p.m. with the resident in the dining room revealed she returned from [MEDICAL TREATMENT] around 12:00 p.m. today. She stated she did not like her lunch because they were always putting plain egg noodles on her tray. She pushed her tray away and said out loud, 'I can't live off this, and I can't eat this! Observation of the Diet Card on the resident's tray at this time indicated a Renal Diet. A further interview revealed she goes to [MEDICAL TREATMENT] every M, W, F around 5:30 AM. She eats a bowl of cereal before she leaves and the facility sends her with a peanut butter and jelly sandwich to take with her. She would prefer variation in the snack that is provided her. She is tired of the same thing all the time. On her off [MEDICAL TREATMENT] days she always gets 2 boiled eggs for breakfast and she is sick of that. An Interview conducted on 07/29/15 at 12:53 p.m. with LPN AA revealed that the resident had already asked for an alternate tray and the kitchen was working on something for her to eat because she is on a renal diet. A further interview conducted at 1:58 p.m. revealed the resident usually picks at the renal diet food she is given so that she can request foods she is not supposed to have. An interview conducted on 07/29/15 at 3:00 p.m. with the Direct Care LPN revealed the resident is on a renal diet and is not compliant with this and that she often asks for foods she is not supposed to eat. An interview conducted on 07/30/15 at 3:05 p.m. with the Dietary Manager revealed the diet requisition is completed by the nurse, this could either be a resident request or a Physician Order. If the request comes from a resident and is a down grade in diet, it can be processed without a physician order [REDACTED]. Once the requisition is received, the diet is updated in the Meal Tracker System. The nursing staff that monitors during mealtime would check the diet card and would send a second requisition if the diet has been changed or incorrect. He confirmed there was a requisition and a physician order [REDACTED]. An interview conducted on 07/30/15 at 3:20 p.m. with the Assistant Director of Nursing (ADON) revealed she had spoken with the Nurse Practitioner (NP) related to the dietary change because the Dietary Manager at that time was concerned about the diet change. After that conversation, the order for a regular diet continued but was never changed. She confirmed the diet for this resident should be a regular diet as ordered on [DATE]. |
2018-10-01 |