cms_GA: 5477

In collaboration with The Seattle Times, Big Local News is providing full-text nursing home deficiencies from Centers for Medicare & Medicaid Services (CMS). These files contain the full narrative details of each nursing home deficiency cited regulators. The files include deficiencies from Standard Surveys (routine inspections) and from Complaint Surveys. Complete data begins January 2011 (although some earlier inspections do show up). Individual states are provides as CSV files. A very large (4.5GB) national file is also provided as a zipped archive. New data will be updated on a monthly basis. For additional documentation, please see the README.

This data as json, copyable

rowid facility_name facility_id address city state zip inspection_date deficiency_tag scope_severity complaint standard eventid inspection_text filedate
5477 PRUITTHEALTH - OCILLA 115608 209 WEST HUDSON STREET OCILLA GA 31774 2015-03-26 514 D 0 1 ZJXE11 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon record review and staff interviews the facility failed to ensure that non-pressure wounds were assessed and documented for one (1) resident #44 of of twenty four (24) sampled residents. Findings include: Record Review of the Minimum Data Set (MDS) revealed the resident was admitted to the facility on [DATE] with the following diagnoses, included but not limited to: High Blood Pressure, Diabetes, [MEDICAL CONDITION], Parkinson Disease, [MEDICAL CONDITION] and [MEDICAL CONDITION] disorder. Review of the laboratory results revealed a Culture and Sensitivity of the Left Buttock with a heavy growth of Staphylococcus Intermedius, Escherichia Coli and Proteus Mirabilis. Review of the Body Audit Form date 2/8/15 reveals a red open area to the left buttocks although there is no further description of the wound. Record review of the Nurse's Notes dated 2/5/15 at 5:15 p.m. reveals a note Swab for culture done on Left buttock. Record review of the physician telephone orders dated 2/6/15 reveals an order for [REDACTED]. A second physician's order dated 2/9/15 revealed the resident was transferred to Appling Healthcare Services Senior Care Unit due to behaviors. 3/25/15 at 9:00 a.m. the Director of Nursing (DON) was asked for a listing of resident's with wounds in the building for the months of January, (MONTH) and March. An interview with the DON and the Registered Nurse (RN) Consultant AA on the same day at 12:45 p.m. confirms that the resident is not on the wound list for January, (MONTH) and March. An interview on 3/25/15 at 1:16 p.m. with Licensed Practical Nurse (LPN) EE revealed that he/she had filled out the Body Audit Form dated 2/8/15 and that the resident had a sebaceous cyst on his/her buttocks rather than a pressure ulcer. LPN EE agrees the documentation is not clear and does not describe the wound but it should. Record review of the facility Policy and Procedure that was in place during the resident's stay revealed Documentation of Wound Observation and Assessment Form: Policy, Documentation will reflect the current patient/resident status as related to wound care and be completed on patients who receive wound care. Procedure: 1. The licensed nurse will complete the Skin Integrity Documentation as follows: Complete patient/resident's name, physician's name and room number at the top of the page, Check the type of wound, Circle location on body picture of wound and document anatomical location, Date and sign each wound observation and assessment on a separate line, Using key on form, document wound observation and assessment findings. Measure wound once weekly and with any significant changes to the wound. All sections with (*) asterisk, if yes, document additional information in narrative section. Policy for Wound Observation and Assessment: 3. Establish location of wound. The anatomic location of existing wound should be documented. 4. Establish type of wound: Pressure Ulcer and stage. If not pressure ulcer establish partial thickness or full thickness. 7. Use measuring device in cm. Measure wound to determine: length, width, depth. Measure for any tunneling or undermining. 8. Describe the peri-wound (surrounding skin). Describe as intact, dry, macerated, [DIAGNOSES REDACTED], [MEDICAL CONDITION], induration, fluctuance or other 10. Describe the color and type of tissue in the wound bed. There was no evidence the above wound assessment was done. 2018-09-01