cms_GA: 9991
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 |
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9991 | STEVENS PARK HEALTH AND REHABILITATION CENTER, LLC | 115294 | 820 STEVENS CREEK ROAD | AUGUSTA | GA | 30907 | 2011-02-03 | 314 | D | 0 | 1 | LK4P11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record reviews and staff interviews, the facility failed to ensure that two (2) residents (#5, and 37) on a sample of nineteen (19 ) residents received necessary treatments according to the physician's orders to treat pressure sores. Findings include: 1. Review of the admission Minimal Data Set assessment dated [DATE] assessed resident #37 as having two unstageable pressure sores with suspected deep tissue injury. Review of the admission physician's orders dated 12/17/10 revealed the resident was to have wet to dry gauze dressings to the right heel daily. This treatment order continued until 1/26/11. Review of treatment record for December 2010 thru January 25, 2010 revealed the wet to dry dressings were discontinued and to observe the right heel blister, however there was no physician's order in the record to discontinue the wet to dry dressing or to just observe the blister to the right heel. Review of the nursing assessment dated [DATE] revealed that the resident had a blister to the right heel with serous drainage on the dressing when removed and this blister had a small opening. An achilles blister was intact. Review of the Treatment Record-Wound assessment dated [DATE] revealed the right heel measured 7 x 11.3 x 0 and was an unstageable deep tissue injury with light drainage. The last measurement on the right heel done 1/26/10 and measured 3.7 x 4.3 x 0 centimeters in size and was unstageable with no drainage. Observation of the wound care treatment done on 2/2/11 at 8:15 am revealed that the right heel had black eschar. Interview with the Registered Nurse Consultant on 2/1/11 at 9:20 am revealed that the area on the resident's heel was a closed blister and the facility follows their wound protocol for a blister, which was to just observe the blister, until it opens. She further indicated that the admission nurse forgot to write the physician's order to discontinue the wet to dry dressing and just observe the blister. 2. Record review for resident #5 revealed the resident was admitted to the facility on [DATE] after a fall and surgical repair of the left hip. The Foot and Skin Assessment sections of the Nursing Admission assessment dated [DATE] noted a 7.0 centimeter (cm) long by 0.8 cm wide area on top side of left foot, and a 3.5 cm by 1.0 cm area on the outer aspect of the left foot. The area across the left foot was described as having an open yellow base with non-approximated edges. Review of physician's orders from 12/16/10 thru 01/26/11 revealed the dressing for the left foot was to be changed every three days and as needed. Review of the resident's Treatment Records revealed that there was no evidence that the dressing to the left foot was changed between 12/19/10 and 12/24/10; between 12/27/10 and12/31/10; between 12/31/10 and 01/05/11; between 01/12/11 and 01/17/11 and between 01/22/11and 01/26/11. Additionally, there was a notation on the Treatment Record of 'OTA' on 01/14/11 when the dressing was due to be changed. Interview conducted 02/03/11 at 8:30 a.m.with the Wound Care Coordinator Licensed Practical Nurse (LPN) 'AA' revealed that the facility believed the wound on the resident's left foot was caused from compression hose or a protective boot that was too tight when she was in the hospital. "AA" further revealed that the facility nurse assigned to the resident did the ordered dressing changes, as well as weekly skin assessments. She indicated that she observed all the wounds weekly on Wednesdays to measure and assess if the wound was healing, and/or if the wound care consultant needed to be contacted for suggestions. LPN 'AA' revealed that she saw resident #5's foot for the first time on 01/05/11, and verified that the description of the wound on the Admission Assessment was that of an open wound with a yellow base, but stated when she first saw it in January it looked like a line surrounding the entire foot that was purplish,and red in color. She felt like it was deep tissue injury (DTI). She verified there was no evidence that the dressing was changed as ordered on [DATE]; between 01/01/11-01/05/11; and when due on 01/25/11, and she did not know why the dressing was not changed. She thought the abbreviation 'OTA' on the Treatment Record meant the resident was not in the building, but could find no documentation in the nurse's notes to support this. During interview on 02/03/11 at 10:45 a.m. with the Director of Nurses (DON), she indicated that 'OTA' generally meant the resident was out to an appointment, but that the dressing on the left foot should have been changed when the resident returned to the facility. | 2015-03-01 |