cms_GA: 8212
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 |
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
8212 | CARLYLE PLACE | 115680 | 5300 ZEBULON ROAD | MACON | GA | 31210 | 2012-07-31 | 314 | D | 0 | 1 | DIQL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record reviews it was determined that the facility failed to adequately assess a pressure ulcer for one resident (#25) from a sample of twenty seven (27) residents. Findings Include: Review of the clinical record for resident # 25 revealed that the resident was admitted on [DATE] with a [DIAGNOSES REDACTED]. On 6/21/12 the nurses's notes revealed that a Certified Nursing Assistant (CNA) identified a dark area on the right heel and a skin assessment completed on 6/21/12 recorded the area as a stage 1 pressure ulcer on the right heel. However, there were no measurements of the wound noted. Continued review revealed that skin assessments were completed on 6/27/12 and 7/8/12 and continued to identify the area on the right heel as a stage 1 pressure ulcer but there were no measurements of the wound. Review of the thirty (30) day Minimum Data Set (MDS) assessment dated [DATE], assessed the resident as having a deep tissue wound to the right heel, however the computerized 7/21/12 skin assessment noted that the resident had a stage 1 wound to the right heel. There were no measurements of the wound. Interview with the Director of Nurses (DON) on 7/31/12 at 9:15 a.m. revealed that she usually stages the pressure ulcers and that the nurses complete a paper weekly skin assessment of all wounds that include the measurements. Review of the wound notebook with the DON revealed there were no completed skin assessments in the notebook for resident #25. Continued interview revealed that she had identified the resident's wound as a deep tissue wound with the Minimum Data Set nurse, prior to the completion of the 7/12/12, thirty (30) day assessment and that the computerized skin assessment was incorrect. According to the U.S. Department of Health and Human Services Clinical Practice Guideline, Number 15: treatment of [REDACTED]. Pressure sores should be reassessed at least weekly in order to monitor the progress or deterioration of the pressure sores. The weekly assessment should include an accurate measurement of the length, width and depth of the ulcer, a description of sinus tracts, tunneling, undermining, necrotic tissue, or exudate and the presence of absence of granulation and [MEDICATION NAME] (p.25). | 2016-06-01 |