cms_GA: 722
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 722 | BRIARWOOD HEALTH AND REHABILITATION CENTER | 115322 | 3888 LAVISTA ROAD | TUCKER | GA | 30084 | 2017-09-21 | 511 | D | 0 | 1 | 6G1L11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff, and radiology employee interview, the facility failed to obtain the results of an ordered chest x-ray (CXR) in a timely manner for one resident (R) (#157), who was complaining of shortness of breath. The sample size was 32 residents. Findings include: Review of R #157's closed clinical record revealed that she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a hospital History and Physical dated 7/14/17 revealed the resident developed a pneumothorax that necessitated chest tube placement. Review of her risk for altered respiratory status/difficulty breathing related to a recurrent right pleural effusion, status/post right pneumothorax with chest tube, right [MEDICAL CONDITION], and sleep apnea care plan revealed an intervention to observe for signs and symptoms of respiratory distress and abnormal breathing patterns, and report to the physician as needed. Review of a Medical Attending physician progress notes [REDACTED].#157 had a right pleural effusion, shortness of breath, a loud cardiac murmur, and was on [MEDICAL TREATMENT] due to [MEDICAL CONDITION]. Review of the Plan on this progress note revealed for the resident to have a CXR, and oxygen as needed. Review of physician's orders [REDACTED]. Review of nursing progress notes dated 8/7/17 at 3:43 p.m. revealed the physician visited and R #157 complained of shortness of breath, and a new order was received for a CXR. Review of the portable CXR report results done 8/7/17 noted R #157 had a large right pleural effusion, and possible increased density involving the medial right lung apex as well. Further review of the CXR results revealed a dense consolidation involving right perihilar region and medial right lung apex. Further review of the report revealed the CXR was read by the radiologist at 11:02 p.m. on 8/7/17, with a large notation of ALERT printed across the page. Further review revealed a handwritten notation on the report that the results were reported to the attending physician on 8/8/17, with a new order to send to emergency room (ER). Review of an SBAR (Situation-Background-Assessment-Request) Follow up dated 8/8/17 at 10:15 a.m. revealed that R #157's CXR results were received and reported to the physician, and an order was obtained to send her to the hospital ER. Review of a handwritten entry on a Transfer/Discharge Report dated 8/8/17 revealed that the resident had a CXR done on 8/7/17 due to complaints of shortness of breath, and the results revealed a large right pleural effusion with dense consolidation involving the right perihilar region, and that the physician ordered to send the resident to the ER. During interview with Licensed Practical Nurse (LPN) Unit Manager AA on 9/21/17 at 8:20 a.m., she stated that R #157's CXR was ordered by the physician at 2:00 p.m. on 8/7/17, and that per the printing on the top of the CXR report, the CXR was read by the radiologist at 11:02 p.m., and the results were received by fax from the radiology provider on 8/7/17 at 11:21 p.m. She further stated that she thought that when a radiology report had a notation of ALERT across it, that the radiology provider called the facility and spoke to a nurse to ensure they were aware of the result, but could find no evidence that this was done. She further stated that the physician had not ordered the CXR to be done stat or ASAP (as soon as possible), so it was just requested to be done that day. LPN AA stated that if the resident had appeared to be in distress or extremely short of breath, they would have sent her immediately to the ER. LPN Unit Manager AA stated that she discovered R #157's CXR report when she came on duty the next day on 8/8/17, and immediately reported the result to the ordering physician, who ordered for the resident to be sent to the ER. During continued interview, she stated that when something like a CXR was ordered, that it should be discussed in the shift-to-shift nursing report so that the oncoming shift was aware of the order and could watch for the results. She stated that the charge nurse and/or nursing supervisor was responsible for checking the fax machine for any results, and could provide no evidence that this was done. During interview with customer service representative BB from the facility's mobile radiology provider on 9/21/17 at 9:13 a.m., she stated that the radiology technician did R #157's CXR on 8/7/17 at 5:27 p.m., and verified the CXR was read by the radiologist at 11:02 p.m. and faxed to the facility at 11:21 p.m. that night. During further interview, she was not able to determine if anyone from the radiology provider had called to notify the facility staff of the CXR results. During interview with the interim Director of Nursing (DON) on 9/21/17 at 10:10 a.m., she stated that any pending diagnostic test results should be communicated to the oncoming shift so they could watch for it. She further stated she was not aware of any facility policy that addressed this, but that her expectation was for staff to look for test results and address any abnormal results in a timely manner. The DON further stated that a CXR result of a pleural effusion should definitely have been called to the physician as soon as it was received. DONE | 2020-09-01 |