rowid,facility_name,facility_id,address,city,state,zip,inspection_date,deficiency_tag,scope_severity,complaint,standard,eventid,inspection_text,filedate
7816,PRUITTHEALTH - LANIER,115600,2451 PEACHTREE INDUSTRIAL BLVD,BUFORD,GA,30518,2012-01-26,441,E,0,1,GQHX11,"Based on observation, record review and staff interviews the facility failed to ensure that meal trays were distributed in a sanitary manner on one (1) of three (3) halls and that one (1) of three (3) nurses failed to adequately clean and disinfect multi-use glucometers between residents. Findings include: 1. Observation Hall A on 1/23/12 between 12:30 p.m. and 1:30 p.m. of lunch trays being distributed to resident who ate in their rooms. Staff was observed entering resident's room with with the lunch trays adjusting resident's position in bed and wheelchairs then setting up the resident lunch trays touching straws and utensils. Observation at 12:40 p.m. of Certified Nursing Assistant (CNA) KK and another CNA removing pads from the back of resident #44 and then pulled the resident up in bed with the draw sheet and adjusted the resident's covers. The CNA then set the resident's tray up opening a mighty shake and milk then placing straws into both liquids without washing or sanitizing her hands. CNA KK left the room and continued to deliver and set up trays without washing or sanitizing his hands. A second observation of meal service on 1/25/12 between 5:20 p.m. and 6:15 p.m. revealed that CNA LL delivered and set up the dinner tray for resident #102 after adjusting the head of the bed, adjusting the resident's covers. The CNA left the room to deliver and set up trays for other residents without washing or sanitizing his hands. An interview with the Administrator on 1/26/11 at 11:00 a.m. revealed that she expects the staff to wash their hands after adjusting the resident's bed linens or adjusting resident in bed. 2. Observation on 1/24/11 at 4:15 p.m. with Licensed Practical Nurse (LPN) AA of blood sugar check for resident #54. LPN AA cleaned the glucometer with an alcohol wipe, went into the resident's room and preformed a blood glucose check. LPN AA returned to the medication cart at 4:19 p.m., cleaned the glucometer with an alcohol wipe and proceeded to resident #63's room and performed a blood glucose check for this resident. Following the second glucose check, LPN AA returned to the medication cart and cleaned the glucometer with an alcohol wipe. Interview at that time with LPN AA revealed Clorox wipes are available on the medication cart. Review of the facility's policy and procedure for 1/24/12 at 5:30 p.m. revealed that a two step process requiring the glucometer be cleaned with an alcohol wipe then cleaned with a bleach solution wipe was to be done before and after each resident use. The Policy revealed the standardized cleaning and disinfecting procedures will be utilized to promote compliance to manufacturer and CDC guidelines. Review of the manufacture's recommendation for the glucometer revealed: to clean the glucometer with an alcohol wipe then clean with a Clorox solution.",2016-11-01
7858,GOLDEN LIVINGCENTER - WINDERMERE,115291,3618 J DEWEY GRAY CIRCLE,AUGUSTA,GA,30909,2012-01-26,242,D,0,1,BSSQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and staff interview the facility failed to ensure that one (1) resident (D) on a sample of forty-two (42) residents was given the right to choose his/her schedule related to getting up in the morning. Findings include: Review of the annual Minimal Data Set (MDS) assessment dated [DATE] assessed resident D as having a Brief Interview for Mental Status (BIM) score of 12. During interview with the resident on 1/23/12 at 3:44 p.m., the resident revealed that he/she is gotten out of bed early in the morning. The resident revealed that he/she does not like to get up so early and would like to get up when he/she wanted to. Continued interview on 1/24/12 at 2:05 p.m. revealed that staff gets them out of bed between 4:30-6:00 a.m. and he/she did not like getting up that early. The resident stated they did not know why it was necessary to get out of bed so early in the morning. Observation on 1/25/12 at 6:25 a.m. revealed resident D to be dressed, sitting in a wheelchair in the day room and sound asleep. Interview 1/25/12 at 6:35 a.m. with Certified Nursing Assistant (CNA) EE revealed she gets the resident out of bed everyday before 6:00 a.m. When asked if the resident wanted to get up that early, CNA EE commented that in the 5 years she has worked at the facility the resident has always been on the list to be gotten out of bed by the 11-7 staff. Interview with Registered Nurse (RN) Supervisor BB on 1/25/12 at 7:15 a.m. revealed resident D does not like to get up early and should not be on the early out of bed list.",2016-10-01
7859,GOLDEN LIVINGCENTER - WINDERMERE,115291,3618 J DEWEY GRAY CIRCLE,AUGUSTA,GA,30909,2012-01-26,253,B,0,1,BSSQ11,"Based on observation and staff interview, the facility failed to maintain privacy curtains, microwaves and room doors in a clean and well maintained manner for one of two units (1 of 2). Findings include: 1. Observation on 1/25/12 at 1:20 p.m. revealed the door to room 103 to have chipped veneer on the lower outer edge and loose, floppy veneer on the inner lower edge. 2. Observation on 1/25/12 at 3:10 p.m. of room 107 revealed the privacy curtain between the beds to be stained along the lower edge 3. In the Cafe' dining area, the interior ceiling is spattered with grease and dried bits of food particles. Interview on 1/26/12 at 11:45 a.m. with Maintenance and Housekeeping Supervisors confirmed that the above items needed to be repaired, replaced and cleaned.",2016-10-01
7860,GOLDEN LIVINGCENTER - WINDERMERE,115291,3618 J DEWEY GRAY CIRCLE,AUGUSTA,GA,30909,2012-01-26,279,D,0,1,BSSQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, the facility failed to develop care plans related to wheelchair positioning and impaired skin integrity secondary to ongoing scratching behaviors for one (1) resident (#113) from a sample of forty-two (42) residents. Findings include: 1. On 01/24/12 at 7:43 a.m., resident #113 was noted to be in a wheelchair at their bedside. There was no foot support on the wheelchair, and the resident's feet were dangling approximately four inches from the floor. The resident's trunk, head, and neck were leaning to left side. At 12:48 p.m., when the resident was in bed, their wheelchair was noted to have lateral trunk supports, but no leg, head or neck positioning devices. Review of the Annual Minimum Data Set ((MDS) dated [DATE] noted that the resident was totally dependent on staff for all activities of daily living (ADL), and had functional range of motion impairment on one side. Review of the resident's care plans revealed no plans or interventions were developed for wheelchair positioning. Occupational Therapy (OT) Progress Report and Discharge Summary dated 4/22/11 noted the resident was issued short leg rests, a double headrest, step cushion and lateral support for their wheelchair. On 01/25/12 at 1:05 p.m., OT MM verified the wheelchair resident #113 was using was not the one recommended to properly position him/her. On 01/25/12 at 10:35 a.m., MDS Coordinator FF stated that the wheelchair positioning should have been care planned. 2. Review of resident #113's Annual MDS dated [DATE] noted that they had short- and long-term memory problems with severely impaired decision making, and were totally dependent on staff for all ADLs. Review of Physician order [REDACTED]. A Pressure Ulcer care plan was developed, but none of the care plans mentioned skin damage due to chronic scratching. On 01/24/12 at 4:08 p.m., Certified Nursing Assistant (CNA) NN stated the black material under the fingernails of resident #113's left hand was from him/her scratching, and stated she thought the resident had [MEDICAL CONDITION]. On 01/25/12 at 9:30 a.m., CNA OO stated the resident scratches themselves real bad. Observation of the skin revealed that there were numerous long scratch marks on the resident's upper legs, and the resident was noted to scratch their left leg at this time. On 01/25/12 at 12:02 p.m., Treatment Nurse QQ verified the healed and non-healed scratches and scabbed areas to the resident's legs, as well as three scratch marks across the resident's chest. On 01/26/12 at 10:35 a.m., MDS Coordinator FF stated she relied on the Grand Rounds notes and Doctor's Progress Notes prior to doing the annual assessment last August, and neither one mentioned scratching or skin issues, so she didn't develop a care plan.",2016-10-01
7861,GOLDEN LIVINGCENTER - WINDERMERE,115291,3618 J DEWEY GRAY CIRCLE,AUGUSTA,GA,30909,2012-01-26,280,D,0,1,BSSQ11,"Based on record review and staff interview the facility failed to ensure that a care plan was revised related to feeding tubes for one (1) resident (#81) on a sample of forty-two (42) residents. Findings include: Review of the Activities of Daily Living (ADL) care plan initiated on 12/14/11 for resident #81 documented an intervention to provide tube feedings and flushes as ordered. However, there was no evidence that the resident had a feeding tube. Interview with the Registered Nurse Supervisor BB on 1/25/12 at 3:10 p.m. revealed resident #81 had pulled his/her feeding tube out several months prior and the family did not want it replaced. Interview with the Care Plan Coordinator FF on 1/26/12 at 10:50 a.m. revealed the resident's ADL care plan should have been revised to delete the intervention for tube feedings and flushes since the resident no longer had a feeding tube.",2016-10-01
7862,GOLDEN LIVINGCENTER - WINDERMERE,115291,3618 J DEWEY GRAY CIRCLE,AUGUSTA,GA,30909,2012-01-26,282,D,0,1,BSSQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, the facility failed to follow the care plan related to nail care, diabetic foot monitoring, and obtaining podiatry consults; reporting skin abnormalities and conducting weekly skin inspections; turning and repositioning every two hours and floating heels; performing range of motion (ROM); and administering medications as ordered for one (1) resident (#113), who was totally dependent on staff for care. The sample size was forty-two (42) residents. Findings include: Review of resident #113's medical record revealed [DIAGNOSES REDACTED]. The Annual Minimum Data Set ((MDS) dated [DATE] noted the resident was totally dependent for all activities of daily living (ADL). An ADL Care Plan was developed, and included interventions to inspect skin with care, and report reddened areas, rashes, bruising, or open areas to the charge nurse; perform nail care as needed; turn and reposition every two hours and as needed; and perform ROM during care. A Pressure Ulcer Care Plan included interventions to conduct weekly skin inspections; perform diabetic foot monitoring; and float the heels. A Risk for Alteration in Blood Glucose due to Insulin Dependent Diabetes Mellitus Care Plan included interventions for a podiatry consult as needed, and administer medications as ordered. The following observations were made: 1. On 01/24/12 at 10:46 a.m.; 1/24/12 at 12:48 p.m., and 01/24/12 at 4:08 p.m., black material was noted under the fingernails of resident #113's left hand. This was verified by Licensed Practical Nurse (LPN) SS on 01/24/12 at 2:20 p.m., who stated that staff cleaned the resident's nails every two days, but that this was not documented anywhere. The toenails were quite long, especially the second through fifth toes of the left foot, and third toe of the right foot. She added that the resident was seen by a podiatrist, who cut the toenails monthly. On 01/24/12 at 4:08 p.m., CNA NN said anyone could do nail care if they noted that the nails were dirty. On 01/25/12 at 1:35 p.m., CNA RR stated she clipped and cleaned the fingernails three times a week on the shower days, and that the nursing staff was responsible for doing this on the other days. She verified the toenails were long, and said the podiatrist was supposed to cut the toenails. On 01/25/12 at 12:15 p.m., LPN Treatment Nurse TT stated that the nursing staff was responsible for cutting toenails in between the times the podiatrist did. On 01/26/12 at 8:55 a.m., Registered Nurse (RN) Unit Manager BB stated she talked to the podiatrist's office that morning, and he had not seen the resident since June 2011. On 01/26/12 at 9:55 a.m., LPN Treatment Nurse TT stated that the treatment nurses scheduled residents to be seen by the podiatrist, and that diabetic residents were seen on an ongoing basis. She added that the podiatrist was at the facility on 01/18/12, and she did not know why he did not see resident #113. On 01/25/12 at 12:10 p.m., RN Unit Manager BB stated that she thought that diabetic foot monitoring was done at the quarterly review period, and did not know if there was a policy. On 01/26/12 at 7:50 a.m., she stated she still had not been able to find any information on how diabetic foot monitoring was to be done, but thought the podiatrist did it when he saw the resident. On 01/26/12 at 8:58 a.m., the Director of Nurses (DON) stated that diabetic foot monitoring was done on admission, and by the podiatrist thereafter. Cross-refer to F 328. 2. On 01/24/12 at 2:20 p.m., LPN SS assisted with a skin observation of resident #113. There was a circular area of black skin approximately two centimeters in size on the right heel. LPN SS stated she was not previously aware of this blackened area, and that the staff nurses did skin assessments weekly. On 01/25/12 at 9:30 a.m., CNA OO was asked to allow the surveyor to observe the resident's feet. The black circular area to the right heel was easily visible, but the CNA did not remark about it. There were numerous long scratches noted on the residents upper legs, most of them healed, and there was one 1.5 centimeter scabbed area on the left outer knee area. On 01/25/12 at 11:30 a.m., LPN Treatment Nurse QQ stated the staff would verbally tell her when there was a skin issue. She was asked to look at resident #113's feet, and stated the black area of skin on the right heel appeared to be necrosis. She added that nobody had said anything to her about it, and she was not currently doing any treatments to the resident's feet or legs. Review of the Weekly Skin Assessment sheet noted the last skin assessment was performed on 01/16/12, and marked to be due again on 01/23/12. However, the skin assessment was not initialed as being done on 01/23/12. Cross-refer to F 309. 3. On 01/23/12 at 12:56 p.m., 2:10 p.m., and 4:19 p.m., resident #113 was noted on their back in bed with knees drawn up towards the chest. On 01/24/12 at 12:48 p.m., 2:20 p.m., and 4:08 p.m., the resident was in bed on their left side. On 01/25/12 at 7:25 a.m., 9:30 a.m., 11:30 a.m., and 12:00 p.m., the resident was on their right side in bed. On no observations over the four days of the survey were the heels floated or protected in any manner. After observing what she described as necrosis on the resident's right heel on 01/25/12 at 11:30 a.m., LPN Treatment Nurse QQ said the first thing she was going to do was put on some type of heel protection. At 3:07 p.m., RN Unit Manager BB stated that they floated heels by using protective boots. 4. On 01/24/12 at 7:45 a.m., resident #113 was observed to keep their right hand closed in a fist. On 01/24/12 at 10:57 a.m., LPN SS stated the resident had a contracture of the right hand. On 01/25/12 at 9:30 a.m., CNA OO stated she often took care of the resident, but didn't do ROM during care because Restorative did this. At 2:36 p.m., the Assistant Director of Nurses (ADON) stated that the resident had not received Restorative services for at least the past year. At 3:17 p.m., CNA UU stated she thought Restorative did ROM for the resident, but the CNAs didn't. Cross-refer to F 318. 5. Review of the November 2011-January 2012 Medication Administration Records revealed that the resident was receiving insulin according to a sliding scale. In 49 out of 101 opportunities, either the incorrect amount of insulin was given, or there was no documentation that any insulin was given and/or what the blood sugar results were. This was verified by RN Unit Manager BB on 01/26/12 at 10:00 a.m. Cross-refer to F 309.",2016-10-01
7863,GOLDEN LIVINGCENTER - WINDERMERE,115291,3618 J DEWEY GRAY CIRCLE,AUGUSTA,GA,30909,2012-01-26,309,E,0,1,BSSQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to either consistently follow the physician's orders for sliding scale insulin, or document blood sugars or insulin given for two (2) residents (#113, B). In addition, the facility failed to properly position one (1) resident (#113) when in a wheelchair; failed to report skin abnormalities and implement preventive measures to prevent further skin damage for one (1) resident (#113). The facility failed to administered medication as ordered for one (1) resident (#168). The sample size was forty-two (42) residents. Findings include: (1.) Review of resident #113's medical record revealed [DIAGNOSES REDACTED]. Physician's Orders included HumaLog insulin per sliding scale for blood sugars as follows: 100-150= 2 units 151-200= 4 units 201-250= 6 units 251-300= 8 units 301-350= 10 units 351-400= 12 units 401-450= 14 units 451-500= 16 units 501 and above= 18 units Review of November-January insulin records revealed the facility did not give the insulin as per the sliding scale order as follows: November 2011: 1. 10 of 30 times, 2 units of insulin were not given for blood sugars between 100-150. December 2011: 2. 10 of 31 times, 2 units of insulin were not given for blood sugars between 100-150. 3. 3 of 31 times insulin was not documented as given for a blood sugar over 150. 4. 1 of 31 times 2 units was given instead of 4 units for a blood sugar of 151. January 2012: 5. 17 of 40 times no insulin was given for a blood sugar between 100-150. 6. 2 of 40 times there was no documentation of what the BS was. 7. 1 of 40 times 2 units was given instead of 4 units for a blood sugar of 171. 8. 5 of 40 times, there was no documentation that any insulin was given when the blood sugars were between 100-150. On 01/26/12 at 10:00 a.m., Registered Nurse (RN) Unit Manager BB verified the instances noted above where the insulin was not documented or given according to the physician's orders. (2.) Review of resident #113's medical record revealed multiple [DIAGNOSES REDACTED]. The Annual Minimum Data Set ((MDS) dated [DATE] assessed the resident as being totally dependent on staff for all activities of daily living (ADL), with functional range of motion (ROM) impairment on one side. On 01/24/12 at 7:43 a.m., resident #113 was observed in a wheelchair without foot support. The resident's feet were dangling approximately four inches from the floor. His/her trunk, head, and shoulders were leaning to left side. The only adaptive equipment seen in the wheelchair were lateral trunk supports. Review of an Occupational Therapy (OT) Progress Report and Discharge Summary dated 04/22/11 noted a [DIAGNOSES REDACTED]. A sign was noted posted on the wall across from the resident's bed during the survey that had a picture of the wheelchair with all the adaptive equipment labeled, as well as a picture of the resident properly positioned in the chair. On 01/25/12 at 1:05 p.m., OT MM stated the resident had not been seen by OT since April 2011. She said that she recommended at that time that the resident use a highback wheelchair, shortened leg rests to provide foot support, a molded seat cushion, lateral supports to prevent leaning, double head rests, and lateral flexion cervical support. When OT MM observed the wheelchair that was being used for resident #113, she remarked that it was the wrong one, and that there had been an ongoing problem with the wrong wheelchairs being used for residents. (3.) Review of a physician's Nursing Home Visit Report dated 11/06/11 noted that resident #113 had [DIAGNOSES REDACTED]. Physician's Orders included [MEDICATION NAME] 25 milligrams daily for itching, which was originally ordered on [DATE]. There were no treatment orders for any existing skin conditions. A nursing Monthly Summary dated 01/08/12 noted that the resident had a pruritic condition. The Annual MDS dated [DATE] noted the resident was totally dependent on staff for all care. The January skin assessments did not show any skin abnormalities other than an infection around the gastrostomy tube site on 01/02/12. On 01/24/12 at 2:20 p.m., LPN SS stated that the staff nurses did skin assessments weekly. During observation of the resident's skin, she verified a 2 centimeter (cm) circular area of black skin on the right heel which she had not previously been aware of. She also verified that there was dark material under the resident's left fingernails, and stated the resident scratches themself. On 01/25/12 at 11:30 a.m., LPN Treatment Nurse QQ stated that the staff would verbally tell her when there was a skin issue. When she observed the resident's right heel, she stated that it was definitely necrosis, but was not aware of it. She added they were not doing treatments to the scratches on the resident's legs. (4.) Record review for resident B revealed the resident had a [DIAGNOSES REDACTED]. Review of the current January 2012 physician orders documented the resident was to receive [MEDICATION NAME] 45 units subcutaneous daily at 7:30 am as well a [MEDICATION NAME] Regular insulin for sliding scale coverage for finger stick blood sugars (FSBS) before meals and at bedtime. The [MEDICATION NAME] Regular insulin was to be given as follows: FSBS below 65 or above 450 notify the physician 151-200 --- give 2 units 201-250 --- give 4 units 251-300 --- give 6 units) 301-350 --- give 8 units 351-400 --- give 10 units 401-450 --- give 12 units 451-500 --- give 14 units 501 and above give 16 units Review of November 2011 Medication Administration Record [REDACTED] 1. On 11/01/11 and 11/02/11 no FSBS was conducted 2. On six 11/04/11,11/07/11, 11/09/11, 11/23/11, 11/24/11 and 11/25/11 the FSBS was documented as being over 150 (ranging from 152-306). However, no insulin was given as per the sliding scale. 3. On 11/10/11, 11/14/11 the routine [MEDICATION NAME] was held but no indication as to why, nor was there an physician order to hold the [MEDICATION NAME]. Review of the December 2011 MAR indicated [REDACTED] 1. On 12/29/11 at 6:00 a.m. the FSBS 356, at 11:30 a.m. the FSBS was 362 the resident received 8 units of insulin on both occasions, instead of the ordered 10 units as per the sliding scale. 2. On 12/29/11 at 9:00 a.m. when FSBS was 229, no insulin coverage was given. 3. On 12/08/11 and 12/26/11, the routine [MEDICATION NAME] was not given with no documentation as to why it was held. Review of the January 2012 MAR indicated [REDACTED] 1. On 01/06/12 and 01/21/12 the FSBS was not checked as ordered. 2. On 01/03/12 the FSBS was 420 and the resident was given 10 units of [MEDICATION NAME] Regular insulin instead of 12 units as ordered. 3. On 1/14/12, 1/15/12 and 1/23/12 the routine [MEDICATION NAME] was held with no indication as to why. Interview with the Assistant Director of Nursing GG on 1/26/12 at 9:55 a.m. confirmed that physician orders were not been followed related to the routine and sliding scale insulin coverage. (5.) Record review revealed resident #168 had a Physician Order dated 10/28/11 to administer [MEDICATION NAME] (for treatment of [REDACTED]. Hold if the systolic blood pressure(B/P) was less than 100. During the month of November 2011 the medication was administered daily but no blood pressure monitoring was conducted. Record review of documentation provided by the facility on 01/31/12, revealed the resident's B/P was not monitored with administration of the medication until 01/28/12. Interview with Licensed Practical Nurse AA on 01/26/12 revealed that she was not aware of this part of the physician's order. (6.) Record review for resident #168 revealed a Physician order for [REDACTED]. No indication as to why the medication was documented, with the exception of 01/09/12 which contain a notation of not available.",2016-10-01
7864,GOLDEN LIVINGCENTER - WINDERMERE,115291,3618 J DEWEY GRAY CIRCLE,AUGUSTA,GA,30909,2012-01-26,312,D,0,1,BSSQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record and staff interview the facility failed to ensure that one (1) resident (D) on a sample of forty-two (42) residents received the necessary services to maintain personal hygiene related to nail care. Findings include: Review of the annual Minimal Data Set (MDS) assessment dated [DATE] assessed resident D as having a Brief Interview for Mental Status (BIM) score of 12. The resident was also assessed on this MDS as needing extensive assistance with personal hygiene. Observation on Monday, 1/23/12 at 3:50 p.m., on Tuesday 1/24/12 at 7:40 a.m.,11:20 a.m. and at 2:05 p.m. revealed the resident's fingernails to be jagged with a brown substance underneath the nails. Interview with the resident D on 1/24/12 at 2:05 p.m. revealed that he/she is scheduled to receive a shower on Tuesday, Thursday and Saturday but did not receive a shower/bath on 1/24/12. Then resident revealed he/she would like his/her fingernails cleaned. Interview with Licensed Practical Nurse CC on 1/24/12 at 2:08 p.m. confirmed that the resident's fingernails needed to be cleaned. She stated that nail care should be done on the resident's bath days.",2016-10-01
7865,GOLDEN LIVINGCENTER - WINDERMERE,115291,3618 J DEWEY GRAY CIRCLE,AUGUSTA,GA,30909,2012-01-26,318,D,0,1,BSSQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, the facility failed to provide range of motion (ROM) to help prevent any potential decrease for one (1) resident (#113), who was totally dependent on staff for care. The sample size was forty-two (42) residents. Findings include: Review of resident #113's clinical record revealed [DIAGNOSES REDACTED]. The Annual Minimum Data Set ((MDS) dated [DATE] noted the resident was totally dependent for all activities of daily living (ADL); the Functional ROM was assessed as impairment on one side; and that the resident was not receiving skilled therapy or restorative services. An ADL Care Plan included interventions to perform ROM during care, and monitor and report changes in ROM ability. Review of the Certified Nursing Assistant (CNA) Cardex noted that resident #113 was to receive ROM to all joints. On 01/24/12 at 7:45 a.m., resident #113 was observed to keep their right hand closed in a fist. At 10:57 a.m., Licensed Practical Nurse (LPN) SS stated the resident had a contracture of the right hand. On 1/25/12 at 9:30 a.m., CNA OO stated she often took care of the resident, but didn't do ROM during care because the Restorative staff did this. At 2:36 p.m., the Assistant Director of Nurses (ADON) stated that the resident had not received Restorative services for at least the past year. At 3:17 p.m., CNA UU stated she thought that Restorative did ROM for the resident, but the CNAs did not. On 01/25/12 at 1:05 p.m., Occupational Therapist (OT) MM stated she could not remember any problems with contractures for resident #113, and had not received any screening referrals for contractures from nursing for at least the past year. At 1:40 p.m., she stated that the resident had normal right wrist flexion, but extension to neutral only, and slight contractures of the fingers. On 01/25/12 at 3:07 p.m., Registered Nurse (RN) Unit Manager BB stated that the care plan intervention to do ROM during care was supposed to be done by the CNAs.",2016-10-01
7866,GOLDEN LIVINGCENTER - WINDERMERE,115291,3618 J DEWEY GRAY CIRCLE,AUGUSTA,GA,30909,2012-01-26,328,D,0,1,BSSQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview the facility failed to provide care and services related to respiratory care for two (2) residents, resident # 238 and resident C and to ensure diabetic foot care for one resident, resident #113 on a sample of forty-two (42) residents. Findings include: 1. On 1/25/12 at 7:30 a.m. resident # 238 was observed in bed with an empty unsecured oxygen cylinder next to his bed. The nasal cannula was laying on the top of the cylinder exposed to the air. There was no signage on the door indicating oxygen was in use. Review of the nurses notes dated 1/24/12 at 11:40 p.m. revealed that resident #238 had respiratory wheezing and his oxygen (O2) saturation was low at 87% on room air. The physician was notified and orders received for oxygen 2 liters a minute by nasal cannula, [MEDICATION NAME] sulfate jet nebulizer treatments every six (6) hours as needed to address the wheezing and low oxygen saturation. Observation of the resident on 1/25/12 at 8:15 a.m. revealed that Physical Therapy (PT) Technician was performing PROM and the unsecured oxygen cylinder remained next to the bed with the nasal cannula on the top of the cylinder and the resident was not receiving oxygen therapy. Observation at this time, with the West Wing Register Nurse (RN) Unit Manager, revealed the oxygen cylinder should be secured in a holder and the nasal cannula was not stored properly. She stated she was not aware the resident had been put on oxygen. Observation of resident # 238 on 1/25/12 at 10:20 a.m. revealed that he was receiving oxygen by nasal cannula thru an oxygen concentrator at 4.5 liters per minute. This was verified by Licensed Practical Nurse (LPN) LL, who after checking the orders, reduced the flow rate to 2 liters. 2. Interview with resident C on 1/26/12 at 9:50 a.m. revealed that they were on a respiratory machine for sleep apnea. The resident told the surveyor that this was their machine from home and they had used it every night for ten years. The mask and tubing for this machine was observed on the floor under the bed. Review of the initial assessment dated [DATE] revealed that the resident was not assessed as being on a respiratory machine for sleep apnea. Review of the interim care plan revealed that it did not address any respiratory concerns or use of the machine at night when the resident sleeps. Review of the physician orders [REDACTED]. Observation on 10/26/11 at 10:25 a.m. revealed the mask and tubing was off the floor and coiled on the bedside cabinet but not in a storage bag. The machine was not labeled with the resident's name. Review of the nurse's notes from 1/20/12 to 1/25/12 revealed no documentation of the resident needing or using a respiratory machine for sleep apnea at night. Review of the current Medication Administration Record [REDACTED]. Interview with LPN (LL) on 1/26/12 at 10:45 a.m. revealed that she knew the resident had a respiratory machine for sleep apnea in his room. Interview with the R.N. West Wing Unit Manager on 1/26/12 at 10:55 a.m. revealed that she was not aware that resident # C was on a respiratory machine for sleep apnea until just informed by LPN LL. She stated that the family brought in the machine and the night staff were assisting the resident with it's use, but no one else knew about it. 3. Review of resident #113's clinical record revealed [DIAGNOSES REDACTED]. A Diabetes care plan included an intervention for a podiatry consult as needed. A Pressure Ulcer care plan had an intervention for diabetic foot monitoring. On 01/24/12 at 2:20 p.m., Licensed Practical Nurse (LPN) SS verified a two (2) centimeter area of black skin on resident #113's right heel, which she previously was not aware of. The left foot was dry and scaly. The toenails were thick and long, especially the second through fifth toes of the left foot, and the third toe of the right foot. LPN SS stated the resident was seen by a podiatrist monthly, who cut the toenails at that time. On 01/25/12 at 12:10 p.m., Registered Nurse (RN) Unit Manager BB stated she thought that diabetic foot monitoring was done quarterly, but could never find a policy or documentation that this was being done. On 01/26/12 at 7:50 a.m., she said she thought the podiatrist did the diabetic foot monitoring when he visited. At 8:55 a.m., she said the podiatrist told her he had no record of having seen the resident since June of 2011. On 01/26/12 at 8:58 a.m., the Director of Nurses (DON) stated that diabetic foot monitoring was done on admission, and then by the podiatrist who determined how often he would see the resident. On 01/26/12 at 9:55 a.m., LPN Treatment Nurse TT stated they were responsible for scheduling podiatry visits, and that diabetic residents were seen on an ongoing basis. She provided a list of residents scheduled for the podiatrist to see when he was last at the facility on 01/18/12, and resident #113 was on this list. She did not know why the podiatrist did not see the resident. At 11:40 a.m., the DON stated the podiatrist did not see the resident on 01/18/12 because there were so many residents to be seen that day.",2016-10-01
7867,GOLDEN LIVINGCENTER - WINDERMERE,115291,3618 J DEWEY GRAY CIRCLE,AUGUSTA,GA,30909,2012-01-26,333,D,0,1,BSSQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined that for one (1) resident, # 168, the facility failed to prevent significant medication errors from a sample of forty-two (42) residents. Findings include: Record review revealed resident #168 was admitted on [DATE] with multiple [DIAGNOSES REDACTED]. Physician order [REDACTED]. As referenced in Nursing 2011 Drug Handbook, [MEDICATION NAME] is primarily administered for the treatment of [REDACTED]. Review of Medication Administration records (MAR) revealed these medications were administered during November 2011. However, review of the December 2011 records revealed neither the [MEDICATION NAME] or the [MEDICATION NAME] were administered nor discontinued for the month of December. Review of the January 2012 records revealed both medication listed as order 10/28/11 and as being administered. Interview with the Director of Nurses on 01/25/12 at 10:30 a.m. revealed after he reviewed the resident's records, no evidence as to why these two (2) medications were not administered for the 31 days in December.",2016-10-01
7868,GOLDEN LIVINGCENTER - WINDERMERE,115291,3618 J DEWEY GRAY CIRCLE,AUGUSTA,GA,30909,2012-01-26,334,E,0,1,BSSQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to consistently implement their influenza and pneumococcal policies and procedures for eleven (11) of twenty-two (22) residents reviewed. Findings include: The facility's infection control and immunization programs were reviewed on 01/26/12 at 12:00 p.m. with Registered Nurse VV. She stated that for new residents, the Admissions personnel gave immunization education to the resident or responsible party (RP), and got the consent signed for the resident to receive or refuse the influenza and [MEDICATION NAME] vaccines. For residents already in the facility, letters were sent out to the RP in August or September with education and consent forms enclosed. She stated that beginning with the 2011 flu season last October, the facility policy was to get a new consent every year, even if the resident or RP had consented to the immunizations in the past. She said that if the RP didn't respond to the letter, she called them or tried to catch them when they visited. She added that attempts to reach the RP were not documented anywhere, and if she didn't hear from them, she didn't give the vaccine. She stated that she started to put all the immunization information in the computer this past Fall. However, review of the Immunization Report printed from the computer revealed that most resident's immunization information was incomplete. After concerns were noted with three (3) of the five (5) residents originally sampled for immunization review, a total of twenty-two (22) residents were reviewed with concerns for eleven (11) of them (#59, #109, #239, #131, #8, #64, #135, #3, #12, #71 and #16). The concerns included the following: No documentation that the resident or RP refused the vaccine or that a vaccine was given (#12, #71, #3; #109; #239); no immunization form in the medical record, so that immunization status was unknown (#109; #239); an immunization was not given after consent was obtained (#16, #131); no documentation that the facility attempted to reach the RP for consent (#8); and no documentation that the facility attempted to contact the RP annually after initial refusal of a vaccine (#12, #135, #64; #59). Review of the facility's Influenza/Pneumococcal Immunization Guidelines revealed the following: If the resident and/or RP refuses the administration of the vaccine, they will be contacted on an annual basis and again educated on the risks and benefits of the immunization so that another informed consent or refusal may be obtained. The immunization log is to be maintained on the resident's current medical record, and include the administration or refusal of the vaccine. Monitoring compliance includes that the influenza vaccines are administered annually with evidence of consent and education; pneumococcal vaccines are administered on admission; and immunization logs are maintained on each residents medical record.",2016-10-01
7869,GOLDEN LIVINGCENTER - WINDERMERE,115291,3618 J DEWEY GRAY CIRCLE,AUGUSTA,GA,30909,2012-01-26,371,F,0,1,BSSQ11,"Based on observation and staff interview failed to prepare and store food under sanitary conditions related to improper drying of glasses, cleanliness of food carts and cleanliness of the dry storage area related to condensation causing a build-up of mildew on the floor for 94 residents based on a census=104 residents. Findings include: On 1/23/12 at 10:30 a.m. during the initial tour of the kitchen the following concerns were noted: 1. The plastic bin that held the scoops for serving food from the steam table had crumbs in it and the edges and side were sticky. 2. There were two (2) black three (3) tiered carts at the entrance door to the kitchen that had dried food spills and food crumbs on them. There were three (3) food carts with doors on them that had food spills down the outside walls. These carts were used to transport trays to the nursing units. 3. Glasses were observed drying near the dishroom not inverted and interview with Dietary Staff SS at this same time confirmed they were air drying the glasses. On 1/24/12 at 1:10 p.m. observation in the kitchen revealed: 1. The (2) three tiered carts again had cereal crumbs and dried food spills on them. 2. Observation above the door to the walkin freezer revealed a thick build-up of white frost. In the dry storage room which backed up to the walkin- cooler and freezer there was condensation from the freezer dripping down the wall. The baseboard and floor was observed wet with black substance on the floor and baseboard. Interview with the Corporate Registered Dietician (R.D.) consultant at this time confirmed that this was mildew and there was a problem with the walkin-freezer. 3. Observation in the dish room revealed that the dishwasher was placing the clean glasses on a tray and not inverting them to dry. The Consultant R.D. instructed the dietary staff at the dishwasher to invert the glasses for air drying. 4. On 1/24/12 at 1:15 p.m. three (3) of four (4) food carts used to transport food trays to the units were observed to have dried liquid spills and sticky substances on the outside walls. Interview with the Consultant R.D., at this time, revealed the carts needed to be pressure washed.",2016-10-01
7870,GOLDEN LIVINGCENTER - WINDERMERE,115291,3618 J DEWEY GRAY CIRCLE,AUGUSTA,GA,30909,2012-01-26,441,E,0,1,BSSQ11,"Based on observation, record review and staff interview the facility failed to provide a safe and sanitary environment to help prevent the development or transmission of disease and infection related to storage of respiratory care equipment for two (2) residents, residents # 238 and C , for the improper use and storage of the ice scoop on the ice cart and the improper cleaning of the blood glucose monitor by one (1) nurse during the medication pass based on a resident sample of fourty-two (42) residents. Findings include: 1. On 1/25/12 at 7:30 a.m. observation of resident # 238 revealed that there was an oxygen cylinder sitting by his bed with the nasal cannula laying on top of the cylinder exposed to the air. The oxygen cylinder was observed on the refill setting. Observation of resident # 238 on 1/25/2012 at 8:50 a.m. revealed that the oxygen cylinder had been remove from the room and the nasal cannula and tubing was curled up and on the residents top sheet exposed to the air. Interview with Licensed Practical nurse (LPN AA on 1/25/12 at 9:20 a.m. revealed that the nasal cannula should be stored in a bag when not in use. 2. During interview with resident C on 1/26/12 at 9:50 a.m. the resident revealed that they were on a respiratory machine for sleep apnea at night. At this time the mask and tubing for their machine was observed on the floor under the bed. On 1/26/12 at 10:25 a.m. the mask and tubing were observed coiled up on the bedside table. The machine was not labeled and the mask was not stored in a plastic bag. Review of the respiratory therapy infection control policy for the facility revealed that all oxygen tubing, cannulas, nebulizers and masks should be stored in a plastic bag with the resident's name and date when not in use. 3. Observation during medication pass on 1/24/12 at 4:20 p.m. revealed a Licensed Practical Nurse (LPN) HH used the facility's glucometer to check a resident's finger stick blood sugar (FSBS) level. After she completed this check LPN HH took an alcohol wipe and cleaned the insertion site area of the glucometer. The nurse then went on to another resident and used the glucometer to check another second resident's FSBS. Interview with LPN HH on 1/24/12 at 4:50 p.m. revealed she was suppose to use a bleach wipes to clean the glucometer between residents she just used a alcohol wipe to clean it. Review of the facility policy for Blood Glucose Monitor Decontamination documented that after the nurse performs the glucose testing the nurse will use a bleach/EPA registered germicidal wipe to clean all external parts of the monitor. and a second wipe should be used to disinfect the blood glucose monitor. 4. On 01/25/12 at 3:00 p.m., Certified Nursing Assistant (CNA) WW was observed passing ice to three (3) residents on the 500-hall. The ice scoop was placed directly on top of the ice in the ice chest, with the handle touching the ice. Between each resident, CNA WW reached in the ice chest to pick up the scoop, and was not wearing gloves. When asked how CNAs were taught to store the ice scoop, the CNA stated the scoop was stored in a container on the side of the outside of the cart, and verified the scoop had been placed on top of the ice. On 01/25/12 at 3:30 p.m., CNA XX was observed passing ice on the 400-hall to four (4) residents, and noted to place the ice scoop directly on top of the ice each time, and she was not wearing gloves. On 01/26/12 at 12:00 p.m., Registered Nurse (RN) VV stated that the scoop for the ice chest should be stored in a plastic bag or separate container, and that the handle should not touch the ice.",2016-10-01
7871,GOLDEN LIVINGCENTER - WINDERMERE,115291,3618 J DEWEY GRAY CIRCLE,AUGUSTA,GA,30909,2012-01-26,456,F,0,1,BSSQ11,"Based on observation and staff interview the facility failed to maintain in safe operating condition the walkin-freezer in the kitchen related to ice buildup and condensation on an interior wall in the dry storage room for ninety-four ( 94) on oral alimentation. Findings include: On 1/23/12 at 10:30 a.m. initial tour of the kitchen revealed that the walk in freezer was not operating properly. Observation above the door to the walkin freezer revealed a thick build-up of white frost. In the dry storage room which backed up to the walkin- cooler and freezer there was condensation from the freezer dripping down the wall. The baseboard and floor was observed wet with black substance on the floor and baseboard. During kitchen observation on 1/24/12 at 1:10 p.m. in the dry storage room the floor behind the open wire racks on the left side of the room remained wet with a black substance on the baseboard and the floor along nine feet of this wall. Interview with the Corporate Registered Dietician (R.D.) consultant at this time confirmed that this was mildew and there has been a problem with the walkin-freezer. The consultant R.D. accompanied the surveyor into the walkin-freezer and observed the ice on the floor of the freezer and the frost buildup outside the freezer door. She stated they would have to notify the manufacturer for repairs. Cross refer to F371, 01/23/12, example #2.",2016-10-01
8001,RIVERSIDE HEALTH CARE CENTER,115375,5100 WEST ST NW,COVINGTON,GA,30014,2012-01-26,441,D,0,1,ECVV11,"Based on observation, staff and resident interview, and review of the facility policy for storing aerosol equipment, the facility failed to properly store nebulizers for one (2) random resident on one (1) of three (3) halls (200 Hall). Findings include: Observation, during initial tour, on 01-23-12 beginning at 9:30 a.m. revealed a Mabis Minicomp Nebulizer sitting on the bedside table to the left bed 216B. The Nebulizer was sitting directly on the table top, not on a protective barrier or covered and the Nebulizer mask, lying on the Nebulizer, also uncovered. The residents last treatment had been administered at 6:00 a.m. Review of facility policy for storing aerosol equipment revealed that a clean cloth should be placed under and on top of the compressor when not in use. Interview with the Director of Nursing (DON) on 1/25/12 at 3:50 p.m., revealed that the Nebulizers were to be covered with a cloth after use. Telephone interview on 2/6/12 at 10:30 a.m. with the DON revealed that the resident received Nebulizer treatments four times a day at 6:00 a.m., 12 noon, 6:00 p.m. and 12 midnight.",2016-07-01
8002,RIVERSIDE HEALTH CARE CENTER,115375,5100 WEST ST NW,COVINGTON,GA,30014,2012-01-26,463,D,0,1,ECVV11,"Based on observations,staff interviews and review of the facility guidelines for call lights, the facility failed to ensure that the call light system functioned appropriately in six (6) of one hundred and fifty nine (159) resident rooms on one (1) of three (3) halls (400 hall) Findings include: Observations of the resident call light system on the 400 hall on 1/23/12 beginning at 11:30 a.m revealed the following: Room 407B- the call light was attached to the side of the bed and plugged into the wall but the push button was missing from the call light making it impossible to signal for assistance;.Room 408B- the call light was attached to the side of the bed and plugged into the wall but the light failed to light up or sound in the room or at the nurses station; Room 403B-the call light failed to light up or sound in the room or at the nurses station; Rooms 416A and B, and 420A-the call lights failed to light up or sound at the nursing station. Review of the Facility Practice Guidelines for Call Lights revealed that any defective call ligh should be reported to the charge nurse and that maintenance department immediately. Interview with the Maintenance Director on 01-23-12 at 3:00 p.m. and checks of the call lights confirmed that the call lights were not working and need to be fixed. Continued interview revealed that the call lights are checked once a month and that they are fixed when they are found not to be working at that time.",2016-07-01
8105,MEDICAL MANAGEMENT HEALTH AND REHAB CENTER,115692,1509 CEDAR AVE,MACON,GA,31204,2012-01-26,309,D,0,1,C2UY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility failed to obtain radiology services annually as ordered by the physician for one (1) resident (#2) from a sample of thirty nine (39) residents. Findings include: Review of the physician's orders [REDACTED]. Review of the medical record revealed the resident had a history of [REDACTED]. Continued review revealed no evidence that a chest x-ray had been done in 2011. Interview with the Director of Nurses (DON) on 1/25/12 at 3:44 p.m. confirmed that there was no x-ray report from 2011 in the medical record. Interview on 1/26/12 at 1:00 p.m. with the DON revealed the she had received faxed x-rays reports indicating that the resident had chest x-rays 1/1/10, 1/10/12, and 1/17/12 at the Medical Center of Central Georgia. Continued interview revealed that there was no chest x-ray done in 2011.",2016-07-01
8106,MEDICAL MANAGEMENT HEALTH AND REHAB CENTER,115692,1509 CEDAR AVE,MACON,GA,31204,2012-01-26,312,D,0,1,C2UY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to provide appropriate nail care for one resident (#2) from a sample of thirty-nine (39) residents. Findings include: Observation of resident #2 on 1/24/12 at 11:46 a.m. revealed his fingernails were extremely long, extending approximately a half-inch (1/2 inch) past the fingertips. The nails were black with a brown material caked under the right thumbnail. Review of the care plan dated 12/16/11 revealed the resident had a self care deficit related to [MEDICAL CONDITION] with [MEDICAL CONDITION]. Interventions included: Staff to assist with bathing, dressing, hygiene and grooming needs. Keep fingernails trimmed and clean. Interview with the Assistant Director of Nurses, on 1/25/12 at 8:51 a.m. revealed she was aware of the resident's fingernails but had not asked the medical director about resident #2's nails. Interview with the medical director, on 1/26/12 at 7:46 a.m. revealed he was not aware of the resident's issue with his fingernails. The physician examined the resident, gave a verbal order for [MEDICATION NAME] cream to be applied and indicated that he had a special tool that would enable him to cut the resident's nails.",2016-07-01
8107,MEDICAL MANAGEMENT HEALTH AND REHAB CENTER,115692,1509 CEDAR AVE,MACON,GA,31204,2012-01-26,329,E,0,1,C2UY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to ensure that the residents' drug regimens were free from unnecessary drugs as evidenced by inadequate monitoring and inadequate indications for its use for two (2) residents (#71 and #91) from a sample of thirty-nine (39) residents. Findings include: 1. Resident #2 is a [AGE] year old admitted [DATE] with Diagnoses: [REDACTED]. Review of the medications the resident was receiving revealed there was no [DIAGNOSES REDACTED]. Review of the consultant pharmacist's review from 1/26/12 revealed diagnoses were needed for Sodium [MEDICATION NAME] and Pantoprazole. 2. Resident #91 is a [AGE] year old admitted [DATE] with Diagnoses: [REDACTED]. Review of the medications the resident is receiving revealed there was no [DIAGNOSES REDACTED]. Review of the consultant pharmacist's review dated 1/26/12 revealed he had requested diagnoses for the medications listed above.",2016-07-01
8108,MEDICAL MANAGEMENT HEALTH AND REHAB CENTER,115692,1509 CEDAR AVE,MACON,GA,31204,2012-01-26,441,F,0,1,C2UY11,"Based on observation and staff interview, the facility failed to maintain appropriate infection control measures to prevent the likelihood of the spread of infection for two (2) ice scoops and failed to clean glucometers according to the facility policy on two (2) medication carts on two (2) of four (4) units. Findings: 1. Observation on 1/24/12 at 12:50 p.m. revealed an uncovered ice scoop on a tray on top of the ice machine in the kitchen. The plastic ice scoop was turned upside down and placed on the tray after a kitchen staff member scooped ice out of the machine. Interview on 1/25/12 at 3:25 p.m. with the Dietary Manager confirmed the covered ice scoop container on the side of the ice machine in the kitchen was broken. She verified the ice scoop was lying uncovered on a tray on top of the ice machine. 2. Observation on 1/25/12 at 11:55 a.m. revealed a Certified Nursing Assistant (CNA) enter the Pantry closet on C Hall to get ice water for a resident. The plastic ice scoop touched the Pantry door when removed from the mesh container and also when replaced in the mesh container. Continued observation at 12:30 p.m. revealed that a Licensed Practical Nurse (LPN) used this plastic ice scoop, from the C Hall pantry, to fill a pitcher with ice and water to use on the B Hall Medication Cart for Medication Pass. 3. Observation on 01/24/12 at 11:44 a.m. revealed Licensed Practical Nurse (LPN) CC preparing to perform a glucose check on a random resident during medication administration on B Unit. After performing the fingerstick, the LPN brought the glucometer back to the medication cart, placed it in a sani-cloth, put it in a cup and laid it in the medication cart, never wiping it to clean. 4. Observation of LPN BB on 1/25/12 at 4:48 p.m., preparing to perform a blood glucose test on Hall C, revealed that the LPN did a cursory wipe of the blood sugar machine before use. After she finished checking the fingerstick blood sugar, she wrapped the machine in a Sani Cloth and put it in the drawer where it stayed for more than 15 minutes. Interview with LPN BB on 1/25/11 at 5:00 p.m. revealed she would remove the Sani Cloth before the 11-7 shift came on duty. Continued interview revealed that she does not always wrap the machine in a wipe after using it but always cleans the machine before using it. Review of the facility's protocol for Capillary Blood Sampling (Finger Stick) and Machine Decontamination revealed the machine is to be thoroughly wiped after use, wiped with a second wipe, and wrapped with the second wipe to allow the machine to remain wet for the recommended 2 to 5 minute decontamination time.",2016-07-01
8109,MEDICAL MANAGEMENT HEALTH AND REHAB CENTER,115692,1509 CEDAR AVE,MACON,GA,31204,2012-01-26,502,D,0,1,C2UY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to follow the physician's orders for laboratory testing for two (2) residents (#33and # 20) from a sample of thirty-nine (39) residents. Findings include: 1. Review of the physician's orders for resident #33 revealed a current order for an Ammonia level, Liver Function tests, and a [MEDICATION NAME] level every three (3) months. Review of the laboratory results revealed that these laboratory test had been done in July, 2011. There was no evidence that these laboratory tests were completed in October, 2011 as ordered. Telephone interview on 2/9/12 at 3:00 p.m., during Quality Assurance, with the Administrator revealed that there was no evidence that this testing had been done in October. 2. Review of the physician's orders for resident #20 revealed a current order for a [MEDICATION NAME] level every three (3) months. Review of the laboratory results revealed that a [MEDICATION NAME] level had been done in June, 2011 and not again until November, 2011. There was no evidence that this laboratory test was done in September, 2011 as ordered. Telephone interview on 2/9/12 at 3:00 p.m., during Quality Assurance, with the Administrator revealed that there was no evidence that this testing had been done in September.",2016-07-01
8190,PRUITTHEALTH - SYLVESTER,115629,104 MONK STREET,SYLVESTER,GA,31791,2012-01-26,167,C,0,1,O3X711,"Based on observation and interviews with a resident and a staff, it was determined that the facility had failed to post a notice of the location and availability of the results of the most recent state inspection. Findings include: During an interview on 1/24/12 at 10:20 a.m., resident A stated that he/she did not know where the most recent state inspection results were posted. On 1/26/12 at 9:30 a.m., the Assistant Director of Nursing (ADON) stated that the results of the most recent state inspection were posted in the activity room. She stated that the notices about their location and availability had been posted on the walls but, someone had taken them down. On 1/26/12 at 9:45 a.m., the results of the most recent state inspection were observed to have been posted on a wall in the activity room.",2016-06-01
8191,PRUITTHEALTH - SYLVESTER,115629,104 MONK STREET,SYLVESTER,GA,31791,2012-01-26,225,E,0,1,O3X711,"Based on record review and staff interview, it was determined that the facility failed to ensure that the results of the pre-employment background checks were obtained within an appropriate timeframe to use for screening two (2) of the eight (8) employees hired in the last 12 months. Findings include: 1. The facility had obtained the criminal background check results for one certified nursing assistant (CNA) on 11/29/11. However, the CNA did not begin employment at the facility until 1/17/12, 49 days after the results of his/her background check were obtained. 2. The facility had obtained the criminal background check results for one certified nursing assistant (CNA) on 6/28/11. However, the CNA did not begin employment at the facility until 9/12/11, 76 days after the results of his/her background check were obtained. During an interview on 1/26/12 at 1:06 p.m., the Assistant Director of Nursing (ADON) stated that she did not know why the criminal background check results for those employees were not obtained timely.",2016-06-01
8192,PRUITTHEALTH - SYLVESTER,115629,104 MONK STREET,SYLVESTER,GA,31791,2012-01-26,241,B,0,1,O3X711,"Based on random observations and a staff interview, it was determined that the facility failed to provide five to eight of the residents with non-disposable spoons during lunch. Findings include: During observations of lunch having been served in the main dining room on 1/23/12 at 12:40 p.m., on 1/24/2 at 12:45 p.m. and 1/25/12 at 12:45 p.m., five (5 ) to eight ( 8) residents were observed eating with plastic spoons. In an interview on 1/26/12 at 9:55 a.m., the Dietary Manager stated that the kitchen staff had just told him that they had run out of metal spoons. After surveyor inquiry at that time, the Dietary Manager stated that he was going to buy more eating utensils.",2016-06-01
8193,PRUITTHEALTH - SYLVESTER,115629,104 MONK STREET,SYLVESTER,GA,31791,2012-01-26,253,D,0,1,O3X711,"Based on observations, it was determined that the facility failed to maintain an environment free of worn wooden finishes on a table and chairs, holes in/or torn vinyl chairs and dusty light fixtures in two day rooms (South and Wing 2), a dining room, and the main entrance. Findings include: Observations were made on 1/25/12 at 3:30 p.m. and on 1/26/12 at 3:26 p.m. South Hall Day Room 1. The finish had been worn off of the arms of seven wooden chairs so, the bare wood was exposed. 2. There were two holes in the seat cushion of an overstuffed, vinyl chair. Both of the vinyl covered arms were torn. There was food debris beneath the seat cushion. 3. Two beds, three wheelchairs and a mechanical lift were being stored in that room. Dining Room 4. Dust and dead bugs were on the inside wall of the fluorescent light fixture that was directly above a dining room table. The light fixture did not have a cover on it. Wing 2 Day Room 5. A bed, a recliner, two mechanical lifts, walk-on scale, and two overbed tables were stored stored in that room. Main Entrance 6. The sections of the finish on the top of the decorative, wooden table had been worn off in so that the bare wood was exposed.",2016-06-01
8194,PRUITTHEALTH - SYLVESTER,115629,104 MONK STREET,SYLVESTER,GA,31791,2012-01-26,273,D,0,1,O3X711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined that the facility failed to complete an initial Minimum Data Set (MDS) for a comprehensive assessment for two (2) residents from a sample of 17 residents. Findings include: The State Agency generated report of the facility's Missing/Late MDS assessments was reviewed with MDS coordinator BB on 1/24/12 at 3 p.m. and on 1/25/12 at 1:15 p.m. The facility failed to complete two residents' required MDS for their comprehensive admission assessments. 1. One resident was admitted to the facility on [DATE]. Staff should have completed his/her MDS within 14 days of the admission (9/13/11), however, staff did not complete it. 2. The admission MDS was due to have been completed for one resident prior to his/her death in the facility on 10/29/10 but, staff did not do it.",2016-06-01
8195,PRUITTHEALTH - SYLVESTER,115629,104 MONK STREET,SYLVESTER,GA,31791,2012-01-26,275,D,0,1,O3X711,"Based on record review and staff interview, it was determined that the facility failed to complete a comprehensive assessment at least every 366 days for one resident from a sample of 17 residents. Findings include: The State Agency generated report of Missing/Late MDS assessments was reviewed with MDS coordinator BB on 1/24/12 at 3 p.m. and on 1/25/12 at 1:15 p.m. One of the seventeen residents listed in the report did not have his/her comprehensive assessment completed timely as required. One resident had an annual comprehensive MDS completed by staff on 4/24/10. The staff should have completed the next required annual comprehensive assessment in April 2011 but, they did not do it. The facility did not complete a comprehensive assessment of the resident until 5/23/11, when there had been a significant change in his/her condition.",2016-06-01
8196,PRUITTHEALTH - SYLVESTER,115629,104 MONK STREET,SYLVESTER,GA,31791,2012-01-26,279,D,0,1,O3X711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined that the facility failed to develop a comprehensive plan of care to address the level of assistance needed to ensure continence as possible for one resident (B) resident from a sample of 32 residents. Findings include: Resident B was admitted with [DIAGNOSES REDACTED]. According to his/her most recent Minimum Data Set (MDS) assessment dated [DATE], staff had coded him/her as having been continent and requiring the assistance of two people for transfers. They coded the resident as having had diminished cognition and was never understood. His/Her care plan since 11/10/11 addressed the resident's impaired mobility as well as interventions for nursing staff to assist him/her with activities of daily living (ADLs) as needed, and to observe his/her skin during incontinence care as well as to check him/her for incontinence every two hours and as needed. However, the facility failed to develop a comprehensive care plan which addressed the fact that the resident was continent and should be offered the opportunity to go to the bathroom.",2016-06-01
8197,PRUITTHEALTH - SYLVESTER,115629,104 MONK STREET,SYLVESTER,GA,31791,2012-01-26,282,D,0,1,O3X711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and staff interview, it was determined that the facility failed to implement the plan of care for one resident (#47) who was at high risk for developing pressure ulcers and to administer pain medication as ordered for one resident (#2) from a total sample of 33 residents. Findings include: 1. Resident #47 was assessed and coded by the facility on the 1/6/12 quarterly Minimum Data Set assessment as at risk for pressure sores and as having a history of pressure sores. The resident had a care plan since 1/11/12 with interventions for nursing staff to apply heel protectors and to float his/her heels as needed, to turn and reposition him/her every two hours and, for a pressure relieving mattress to be on the resident's bed. However, it was observed that the resident remained positioned in the bed positioned on his/her right side and laying on a deflated air mattress on 1/24/12 at 8:15 a.m., 9:05 a.m., 10:20 a.m. and at 11:15 a.m. There were not any pressure relieving device between the resident's knees or feet. Also during those observations, the resident was not wearing any heel protectors and his/her heels were not floated as instructed in the plan of care. Additional observations were made of the resident laying in the bed on a deflated air mattress with his/her heels resting directly on the mattress without wearing any heel protectors on 1/23/12 at 2:45 p.m. and 4:00 p.m., 1/25/12 at 10:00 a.m. and 10:30 p.m. and on 1/26/12 at 9:00 a.m. and 11:20 a.m. During an observation and interview with licensed staff AA on 1/26/12 at 11:20 a.m., he/she confirmed that the air mattress was deflated because it was unplugged from the wall. He/she also stated that the mattress that was underneath the air overlay was not a pressure relieving mattress. See F314 for additional information regarding resident #47. 2. Resident #2 had a care plan since 8/17/11 to address his/her risk for pain and discomfort related to peripheral [MEDICAL CONDITIONS] and joint contractures. There was an intervention for licensed nursing staff to medicate him/her as ordered. The resident had a physician's orders [REDACTED].#3 three times a day. However, review of the nursing staff's documentation on the resident's January 2012 Medication Administration Record [REDACTED]. See F309 for additional information regarding resident #2.",2016-06-01
8198,PRUITTHEALTH - SYLVESTER,115629,104 MONK STREET,SYLVESTER,GA,31791,2012-01-26,287,C,0,1,O3X711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined that the facility failed to complete a Discharge or Death in facility Minimum Data Set (MDS) assessment for 9 residents and failed to electronically transmit a completed 5 day Medicare part A, 14 day Medicare part A and admission MDS for 1 resident, and Discharge or Death in facility MDS assessments to the State for 7 residents from a total sample of 17 residents. Findings include: The State Survey Agency generated report about Missing/Late MDS was reviewed with MDS coordinator BB on [DATE] at 3 p.m. and on [DATE] at 1:15 p.m. Sixteen of the seventeen residents listed in the report did not have Discharge or Death in facility MDS assessments completed within seven days or electronically transmitted to the State as required at least monthly. 1. One resident was discharged from the facility on [DATE]. However, a Discharge assessment was not completed. 2. One resident expired in the facility on [DATE]. However, the Death in facility assessment was not completed and electronically transmitted to the State until [DATE]. 3. One resident was discharged from the facility on [DATE]. However, a Discharge assessment was not completed. 4. One resident expired in the facility on [DATE]. The Death in facility assessment was completed on [DATE] but not electronically transmitted to the State. 5. One resident expired in the facility on [DATE]. However, the Death in facility assessment was not completed and electronically transmitted to the State until [DATE]. 6. One resident was discharged from the facility on [DATE]. However, a Discharge assessment was not completed. 7. One resident had a 5 day Medicare part A assessment completed on [DATE], and a 14 day Medicare part A and admission assessment completed on [DATE]. However, the assessments were not electronically transmitted to the State until after surveyor inquiry on [DATE]. In addition, this resident was discharged from the facility on [DATE]. However, a Discharge assessment was not completed. 8. One resident was discharged from the facility on [DATE]. A Discharge assessment was completed but not electronically submitted to the State until after surveyor inquiry on [DATE]. 9. One resident was discharged from the facility on [DATE]. A Discharge assessment was completed but not electronically submitted to the State until after surveyor inquiry on [DATE]. 10. One resident expired in the facility on [DATE]. A Death in facility assessment was completed but not electronically submitted to the State until after surveyor inquiry on [DATE]. 11. One resident was discharged from the facility on [DATE]. However, a Discharge assessment was not completed. 12. One resident was discharged from the facility on [DATE]. However, a Discharge assessment was not completed. 13. One resident was discharged from the facility on [DATE]. A Discharge in facility assessment was completed but not electronically submitted to the State. 14. One resident was discharged from the facility on [DATE]. A Discharge in facility assessment was completed but not electronically submitted to the State. 15. One resident expired in the facility on [DATE]. However, a Death in facility assessment was not completed. 16. One resident was discharged from the facility on [DATE]. A Discharge assessment was completed but not electronically submitted to the State.",2016-06-01
8199,PRUITTHEALTH - SYLVESTER,115629,104 MONK STREET,SYLVESTER,GA,31791,2012-01-26,309,D,0,1,O3X711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, it was determined that the facility failed to administer a pain relief medication as ordered for one resident (#2) from a total sample of 33 residents. Findings include: Resident #2 had a care plan since 8/17/11 to address his/her pain and discomfort related to his/her [DIAGNOSES REDACTED]. The interventions included that licensed nursing staff were supposed to medicate the resident as his/her physician ordered. The resident had a physician's orders [REDACTED].#3 three times a day as well as a as needed order for [MEDICATION NAME]. Although, there was nursing staff's documentation on the resident's January 2012 Medication Administration Record [REDACTED]. Nursing staff documented on the back of the MAR indicated [REDACTED]. A licensed nurse documented in the 1/20/12 at 7:30 a.m. nurses notes that the pharmacy and (facility) staff had tried to contact the resident's doctor because, the resident had been out of Tylenol #3 since 1/8/12. During an interview on 1/26/12 at 1:45 p.m., the Director of Nursing stated that the resident's attending physician had been unavailable during that time so, the order to refill the prescription for the Tylenol #3 was not signed. Tylenol #3 was not given as ordered from 1/8/12 until the 1/20/12 order to discontinue it.",2016-06-01
8200,PRUITTHEALTH - SYLVESTER,115629,104 MONK STREET,SYLVESTER,GA,31791,2012-01-26,314,D,0,1,O3X711,"Based on observations, record review, and staff interview, it was determined that the facility failed to ensure that interventions to promote healing and prevent pressure sore development were implemented for one resident (#47), who was at high risk for developing pressure ulcers from a total sample of 33 residents. Findings include: Resident #47 was assessed and coded by the facility on the 1/6/12 quarterly Minimum Data Set assessment as at risk for developing pressure sores and as having a history of pressure sores. The resident had a 1/11/12 care plan with interventions to attempt to prevent pressure sores from developing which included the use of heel protectors and to float heels as needed, for staff to turn and reposition him/her every two hours and for the use of a pressure relieving mattress on his/her bed. When the resident was observed in the bed on 1/24/2012 at 8:15 a.m., 9:05 a.m., 10:20 a.m. and at 11:15 a.m., the right side of the air mattress was not inflated and the resident had been positioned on his/her right side. There was not any pressure relieving device between the resident's knees or feet. Also during those observations, the resident was not wearing heel protectors and his/her the heels were not floated. The resident was observed laying in the bed on a deflated air mattress with his/her heels resting directly on the mattress and without any heel protectors in use on 1/23/12 at 2:45 p.m. and 4:00 p.m., 1/25/12 at 10:00 a.m. and 10:30 p.m. and on 1/26/12 at 9:00 a.m. and 11:20 a.m. During an observation and interview on 1/26/12 at 11:20 a.m., licensed nurse AA confirmed that the air mattress was deflated and said that it was unplugged. He/she stated that the mattress that was underneath the air overlay was not a pressure relieving mattress.",2016-06-01
8201,PRUITTHEALTH - SYLVESTER,115629,104 MONK STREET,SYLVESTER,GA,31791,2012-01-26,371,F,0,1,O3X711,"Based on observations, staff interview and record review, it was determined that the facility failed to ensure that the temperature in the ice cream freezer was maintained at a level to keep the ice cream frozen. Findings include: On 1/26/12 at 9:45 a.m. and at 1:35 p.m., the temperature in the ice cream freezer was 20 degrees Fahrenheit. The tubs of ice cream and sherbet were soft to touch. Some of the melted ice cream and sherbet had leaked out of their cardboard containers. Four cases of Magic Cup ice cream (dietary) supplement were soft. Inside the case that staff had opened, it was observed that several individual cups had busted and the Magic Cup ice cream was exposed. At that time, the Dietary Manager stated that the box of Magic Cup should have been removed. Review of the staff's documentation on the facility's Refrigeration Temperature log form revealed that the freezer temperature that morning had been a negative 10 degrees Fahrenheit. Staff's documentation of the freezer temperatures for January 2012 ranged from a negative 20 degrees to zero degrees. The Dietary Manager stated at that time that they had not had any problems with the ice cream freezer.",2016-06-01
8202,PRUITTHEALTH - SYLVESTER,115629,104 MONK STREET,SYLVESTER,GA,31791,2012-01-26,463,E,0,1,O3X711,"Based on observation and staff interview, it was determined that the facility failed to maintain a functioning call system in one of four common baths (Wing I Women's Bath) and in the common bathroom for rooms 11 and 12. Findings include: 1. During the tour on 1/23/12 at 11:30 a.m., the call light next to the toilet in the Wing I women's bath would not stay pressed in when pushed and the light did not work. A certified nursing assistant (CNA) verified that the call light did not function properly. It was observed on 1/23/12 at 4:00 p.m., 1/24/12 at 8:00 a.m., 9:40 a.m., 12:05 p.m., 2:00 p.m., and 4:45 p.m., 1/25/12 at 7:15 a.m., 9:50 a.m., 11:30 a.m. and 2:00 p.m., that the light did not turn on when the call light button was pushed. During an interview on 1/25/12 at 2:05 p.m., the maintenance supervisor was unaware of the call light not functioning properly. 2. On 1/23/12 at 4:37 p.m. and on 1/6/12 at 12:05 p.m., the call light in the common bathroom for rooms 11 and 12 did not work. On 1/26/12 at 12:10 p.m., the unit manager for Wing I stated that three of the four residents in those rooms were capable of using the call light in the bathroom. On 1/26/12 at 12:40 p.m., the maintenance supervisor stated that he was unaware that the call light did not work. He stated that he randomly checked the call lights in the residents' rooms once a month but, he did not document which rooms he checked. He stated that he did not know the last time that the all light for the bathroom for rooms 11 and 12 was checked.",2016-06-01
8429,SIGNATURE HEALTHCARE OF MARIETTA,115206,811 KENNESAW AVENUE,MARIETTA,GA,30060,2012-01-26,166,D,0,1,M1EI11,"Based on review of medical records, the facility's Grievance Log, Policy/Procedure for Investigating a Grievance or Complaint, and residents and staff interviews, the facility failed to follow the facility's policy to document grievances/complaints and ensure that residents received timely response to grievances/complaints for two (2) residents (A and X ) from a sample of thirty three (33) residents. 1. Interview on 1/24/12 at 10:34am with resident X revealed that a pair of black pants and two (2) brand new suits were missing. The suits had been were given to him/her on his/her birthday in June. Resident X further revealed that the clothes were labeled and reported to the laundry personnel and other staff. Resident X has had no information/response regarding the missing clothes. Review of the medical record for resident X indicated there was no evidence in the Social Service notes regarding the resident's complaints about missing clothing. Review of the Grievance Log from Jan. 1, 2011 through Jan. 24, 2012 revealed there were no grievances in the log related to resident's missing clothes. Interview with laundry staff DD on 1/24/11 at 3:00pm revealed she writes missing items in a note book however does not usually fill out a grievance/complaint form. She will search for the missing items and if not found will report to Social Services who will talk with the resident. Interview with the Social Services Director CC on 1/25/12 at 11:02am revealed she had heard nothing about resident X missing any clothing. At 1:06pm CC revealed that after talking with resident X a grievance/complaint form was completed on the missing clothing. CC was planning on contacting the family to find out more specific information on the clothing. 2. During an interview with resident A on 1/23/12 at 1:42pm, the resident revealed that after her admission on 7/12/10, she sent underwear and a new yellow blouse to the laundry. The resident indicated she does not care about the underwear but the blouse was a gift from her son and had only been worn one (1) time. Several weeks later, she saw the same blouse on another resident, but that resident informed staff that her daughter had purchased that blouse for her. The clothes are still missing, there has been no further follow up or reimbursement. Laundry staff was notified of the missing clothes. Review of the grievance log from 6/2010 through 1/2012 revealed no evidence of a grievance/complaint for these missing items. Interview with the Laundry Supervisor DD on 1/24/12 at 3:00pm revealed that if a resident reports items missing, Social Services is notified. This requires a search through the facility generally for several days. The no name clothes are also searched. If the search is not successful then Social Services discusses the issue with the resident and makes reimbursement plans. Every effort is made to reimburse the resident for missing items not found. Laundry does not initiate any forms except general description note for the search. Interview with the Director of Nursing on 1/25/12 at 7:45am revealed the facility reports missing items to Social Services, and if clothes to the Laundry. A search is conducted for the missing items. If staff are unable to find the items, the resident is occasionally reimbursed for items according to the Administrator and Social Services decision. Social Services does all investigations and documentation. Review of social services notes for resident A since admission indicated there was no documentation concerning missing clothes. Interview with the Social Services Director CC on 1/25/12 at 8:00am revealed that if a resident reports missing items, they are interviewed for clarification, the resident's inventory list is checked, missing clothing is reported to the laundry staff, and a search conducted. Labeled clothing is usually easy to find, if not labeled might take a while to find. If the missing items are not located, an offer is made to reimburse. The final decision to reimburse is made by the Administrator. If the item is not found a grievance/complaint is generated. Upon completion of the investigation a grievance is filed in the grievance book/log. CC had no knowledge of this complaint. Review of the facility policy/procedure for Investigating a Resident Grievance or Complaint indicated: 1. Social Services was responsible for investigating grievances/complaints. 2. All complaints should be documented on Grievance/Complaint report 3. The report would include date/time, nature of grievance, resident's account, resolution, and date resolution reported. 4. Grievance will be reviewed by the Administrator with in three (3) days of the receipt of the complaint 5. The resident will be informed of the findings and corrective actions 6. All will be documented in the medical record, and grievance log 7. The completed grievance form will be maintained in the Administrators or Social Services office.",2016-01-01
9720,KINDRED TRANSITIONAL CARE AND REHAB - LAFAYETTE,115360,110 BRANDYWINE BOULEVARD,FAYETTEVILLE,GA,30214,2012-01-26,328,D,1,0,5SCS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, facility staff interview, physician interview, and respiratory therapist interview, the facility failed to administer oxygen at the rate ordered by the physician for one (1) resident (#2), who had a tracheotomy, of the sampled sixteen (16) residents. Finding include: Record review for Resident #2 revealed an admission date of [DATE]. A physician's orders [REDACTED]. However, observations of Resident #2 conducted on 01/24/2012 at 9:40 a.m., 10:15 a.m., 11:25 a.m. and 3:15 p.m. revealed the oxygen concentrator flow meter was set on four (4) LPM, instead of two (2) LPM as ordered by the physician. Additional observations conducted on 01/25/2012 at 9:00 a.m. and 10:55 a.m. revealed the oxygen concentrator flow meter remained set at four (4) LPM. During an interview conducted on 01/25/2012 at 9:40 a.m. with the attending physician, the physician stated that Resident #2's oxygen was to be infused at two (2) LPM, per the physician's orders [REDACTED]. During an interview conducted on 01/25/2012 at 10:55 a.m. with the Director of Nursing and the Respiratory Therapist while at the resident's beside, both staff members verified the resident's oxygen concentrator remained at four (4) LPM, not at the two (2) LPM rate as ordered by the physician.",2015-05-01
9721,KINDRED TRANSITIONAL CARE AND REHAB - LAFAYETTE,115360,110 BRANDYWINE BOULEVARD,FAYETTEVILLE,GA,30214,2012-01-26,329,J,1,0,5SCS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and attending physician interview, the facility failed to ensure that the drug regimen of one (1) resident (#1), on the total survey sample of sixteen (16) residents, was free of an unnecessary drug. Specifically, Resident #1, who was ordered to received two (2) doses of KCL 40 milliequivalents (mEq.), was administered four (4) additional doses of the drug and subsequently died after a laboratory test indicated a critical potassium level. Based on the above, it was determined that the facility's failure to administer KCL as ordered by the physician, and thus administering the drug for excessive duration, had caused serious harm to, and contributed to the death of, Resident #1. It was therefore determined that the facility's noncompliance with one or more requirements had resulted in an immediate and serious threat to resident health and safety which was identified to have existed on [DATE] and continued through [DATE], at which time a plan was implemented by the facility to remove the immediate jeopardy situation as of [DATE]. The facility's Administrator and Director of Nursing were informed of this immediate jeopardy on [DATE] at 1:55 p.m. Findings include: Please cross refer to F333 for more information regarding Resident #1. Record review for Resident #1 revealed a Progress Notes entry dated [DATE] at 1:30 p.m. which documented that Resident #1 arrived at the nursing facility. This Note documented that the resident was alert upon admission and was able to ambulate to the bathroom with the assistance of one. A Resident Progress Notes entry of [DATE] at 11:00 p.m. for Resident #1 documented that physician's orders [REDACTED]. [DATE]. However, review of the [DATE] Medication Record (MR) for Resident #1 revealed documentation indicating that Resident #1 actually received 40 mEq. doses of KCL at 9:00 a.m., 1:00 p.m., 5:00 p.m., and 9:00 p.m. on [DATE], and at 1:00 a.m. and 5:00 a.m. on [DATE]. Thus, Resident #1 received an excessive dose consisting of six (6) 40 mEq. doses of KCL, instead of two (2) doses as ordered by the physician. A Laboratory Report for Resident #1, with a draw date and time of [DATE] at 4:30 a.m., documented the results of a BMP laboratory test which indicated that the resident's potassium level was critically high at 8.2 mmol/L (Reference Range, 3.5 - 5 mmol/L). Subsequently, a Resident Progress Notes entry of [DATE] at 2:00 p.m. documented that the nurse had been summoned to the room of Resident #1 and that the resident was observed by the nurse to be unresponsive to verbal stimuli, and to have no respirations, no blood pressure, and no pulse. During an interview with the Resident #1's attending physician conducted on [DATE] at 9:50 a.m., the physician stated that this medication error involving the administration of potassium had been a contributing factor in the resident's death. Based on the above, the facility failed to administer KCL 40 mEq every 4 hours for 2 doses to Resident #1 as ordered by the physician, but rather administered an excessive dose of KCL 40 mEq every 4 hours for a total of six (6) doses, in error. The resident was subsequently determined to have a critically elevated potassium level of 8.2 mmol/L, became unresponsive and died . It was determined that the immediate jeopardy was removed as of [DATE], by which time the facility had completed the following actions. Beginning on [DATE], and continuing through [DATE], the following corrective interventions were being taken by the facility to ensure accurate medication administration: I. On [DATE], four (4) registered nurses and fifteen (15) licensed practical nurses received inservice education on medication errors and verbal/oral telephone orders. The education included face-to-face training on the validation of telephone orders; monitoring of laboratory values; medication effects of high risk medications such as Potassium, [MEDICATION NAME], and Insulin; clarification of medication orders with the physician and/or nurse practitioner; signs of hypo/[MEDICAL CONDITION]; and the policy and procedure for verbal/telephone orders, hand written orders, written transfer orders or faxed orders. II. On [DATE], a process was begun by which newly hired licensed nurses will be educated during the orientation process that will be conducted by the Director of Nursing (DON), Assistant Director of Nursing (ADON), and/or Staff Development Coordinator. III. On [DATE], the licensed nurse who transcribed the KCL order for Resident #1 was removed from the work schedule and suspended pending the results of an investigation by the Georgia Board of Nursing. IV. On [DATE], the Performance Improvement Committee met to address the adverse event and discuss appropriate interventions. The committee consisted of the Administrator, Medical Director, DON, the Admissions Coordinator and the Corporate Risk Manager. V. On [DATE], a process was begun by which new admissions, re-admissions and revised medication orders will be reviewed by the admitting licensed nurse and a second verification will be performed by a registered nurse to assure validity and accuracy of medication orders. The DON, ADON, and Unit Managers will perform a third verification of medication orders to assure validity and accuracy in the Clinical Morning Meeting at least five (5) times a week. The Nursing Supervisor and/or Charge Nurses will be responsible for reviewing and validating new admissions, re-admissions, and revised orders on the weekend. Negative findings through this process will be corrected immediately through physician and/or nurse practitioner notification, and discontinuance of inaccurate medication orders will occur immediately. The institution of the correct transcribed medication order to the telephone order sheet, MR and medical record will be documented as outlined by the policy and procedures. A Medication Variance Report will be completed by the Unit Managers and/or the DON or ADON when medication inaccuracies are identified through this newly adopted, systematic change. This process will be on-going. VI. On [DATE], a process was enacted by which the DON, and/or ADON, and/or Unit Managers will audit new admissions, re-admissions and medication orders in daily clinical review. The results of these audits will be analyzed and reviewed at the facility's monthly Performance Improvement Committee meetings for six months. A subsequent plan will be devised and implemented as needed. This process will be ongoing. VII. On [DATE], a complete review and audit of all resident clinical records was completed by the DON, ADON, and Unit Managers. This review and audit included comparing physicians' orders and telephone orders to the transcribed medication orders on the MRs. VIII. On [DATE], two (2) registered nurses and twenty-seven (27) licensed practical nurses received inservice education on medication errors and verbal/written/oral telephone orders, as described above. IX. On [DATE], ten (10) of the licensed practical nurses and three (3) of the registered nurses who had originally received the [DATE] inservice training referenced above, and four (4) of the licensed practical nurses and one (1) registered nurse who had received the [DATE] inservice training referenced above, received additional inservice training on medication errors, medication transcription, medication administration records, and treatment administration records. In addition, two (2) licensed practical nurses and two (2) registered nurses, with no documented attendance in either of the previous inservice training sessions, received training on this date. Based on these corrective action plans which had been developed and implemented by the facility as outlined above, the immediacy of the deficient practice had been removed on [DATE]. However, the effectiveness of these corrective action plans could not be fully assessed to ensure ongoing application and completion. On [DATE], four (4) registered nurses and fifteen (15) licensed practical nurses received inservice education including medication errors and verbal/oral telephone orders, and on [DATE], two (2) registered nurses and twenty-seven (27) licensed practical nurses received this inservice education. However, on [DATE], ten (10) of the licensed practical nurses and three (3) of the registered nurses who had originally received the [DATE] inservice training referenced above, four (4) of the licensed practical nurses and one (1) registered nurse who had received the [DATE] inservice training referenced above, and two (2) licensed practical nurses and two (2) registered nurses with no documented attendance in either of the previous inservice training sessions, received additional or initial inservice training on medication errors, medication transcription, medication administration records, and treatment administration records. Also, on [DATE], a process was enacted by which the DON, and/or ADON, and/or Unit Managers will audit new admissions, re-admissions and medication orders in daily clinical review, the results of which will be analyzed and reviewed at the facility's monthly Performance Improvement Committee meetings for six months. However, the first meeting of the Performance Improvement Committee to occur after the implementation of the new monitoring procedures and chart audit procedure to begin the process of analyzing the audit did not occur until [DATE], and the committee will not meet again for a month. Therefore, the noncompliance continues, with the scope and severity level of the deficiency decreased to the ""D"" level.",2015-05-01
9722,KINDRED TRANSITIONAL CARE AND REHAB - LAFAYETTE,115360,110 BRANDYWINE BOULEVARD,FAYETTEVILLE,GA,30214,2012-01-26,333,J,1,0,5SCS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, hospital Discharge Summary review, review of the facility's Policy/Procedure for Verbal/Telephone Orders, National Library of Medicine reference information review, facility staff interview, attending physician interview, and physical therapist interview, the facility failed to ensure that each resident was free of any significant medication errors by failing to administer potassium chloride (KCL) in accordance with the physician's orders [REDACTED].#1), of (9) residents on the survey sample who received KCL therapy, and by failing to administer [MEDICAL CONDITION] medication [MEDICATION NAME] in accordance with the physician's orders [REDACTED].#2), on the total survey sample of sixteen (16) residents. Resident #1, who was ordered to received two (2) doses of KCL 40 milliequivalents (mEq), was administered four (4) additional doses of the drug and subsequently died after a laboratory test indicated a critical potassium level. Based on the above, it was determined that the facility's failure to administer KCL as ordered by the physician had caused serious harm to, and contributed to the death of, Resident #1. It was therefore determined that the facility's noncompliance with one or more requirements had resulted in an immediate and serious threat to resident health and safety which was identified to have existed on [DATE] and continued through [DATE], at which time a plan was implemented by the facility to remove the immediate jeopardy situation as of [DATE]. The facility's Administrator and Director of Nursing were informed of this immediate jeopardy on [DATE] at 1:55 p.m. Findings include: 1. Review of the facility's Policy/Procedure for Verbal/Telephone Orders, dated as having been last revised on [DATE], revealed a heading which read ""Caution: Following the procedure below is very important to prevent confusion, medication errors and maintain communication between the disciplines."" Part 2 of the Procedure specified to record the physician's orders [REDACTED]. Record review for Resident #1 revealed a hospital Discharge Summary dated [DATE] which documented that Resident #1 had been admitted to the hospital on [DATE] with [DIAGNOSES REDACTED]. The hospital physician documented that the resident was sitting up in a chair, followed commands, and moved all extremities. The hospital physician also documented that the resident had worked with physical therapy (PT) and occupational therapy (OT) and would be discharged to the nursing facility for rehabilitation. A Resident Progress Notes entry dated [DATE] at 1:30 p.m. documented Resident #1 arrived at the nursing facility, and that the resident was alert upon admission and was able to ambulate to the bathroom with the assistance of one. A Physical Therapy Evaluation dated [DATE] documented that the resident had resided in a personal care home prior to hospitalization . The physical therapist documented that the resident needed stand-by assistance with ambulation, and presented with generalized weakness following hospitalization . The therapist further documented that the resident presented for skilled physical therapy to address the generalized weakness and balance deficits for return to the prior living situation, and with the patient/family goal of returning home. A Daily Patient Services Record documented that on [DATE], the resident began receiving skilled physical therapy services. During an interview with the physical therapist on [DATE] at 1:10 p.m., who had provided physical therapy services to Resident #1, this physical therapist stated that although the resident was weak from dehydration and being in the hospital, once admitted to the nursing facility the resident was ambulating and had made significant progress toward the goal to return to the assisted living setting. The physical therapist stated that it was the plan for the resident to return to the prior living setting. A Resident Progress Notes entry dated [DATE] at 9:00 a.m. documented that the resident had ambulated to the bathroom with assistance of one, responded well to all verbal stimuli, and had attended the facility church services that morning. Review of a Laboratory Report, with a draw date and time of [DATE] at 3:25 a.m., revealed a Basic Metabolic Profile (BMP) which documented Resident #1 to have a low potassium level of 3.3 millimoles per liter (mmol/L), with a reference range listed as 3.5 - 5.0 mmol/L. A Resident Progress Notes entry of [DATE] at 11:00 p.m. documented that physician's orders [REDACTED].#1, signed by Licensed Practical Nurse (LPN) ""DD"", specified an order to administer KCL forty (40) mEq by mouth every four (4) hours times two (2) doses, and also specified a BMP laboratory test to be done on [DATE]. However, review of the [DATE] Medication Record (MR) for Resident #1 revealed that the physician's orders [REDACTED]. Further review of this MR revealed documentation indicating that Resident #1 received 40 mEq. doses of KCL at 9:00 a.m., 1:00 p.m., 5:00 p.m., and 9:00 p.m. on [DATE], and at 1:00 a.m. and 5:00 a.m. on [DATE]. Thus, Resident #1 received a total of six (6) 40 mEq doses of KCL, instead of two (2) doses as ordered by the physician. Resident Progress Notes entries of [DATE] at 9:00 a.m. and 9:00 p.m., and [DATE] at 9:00 a.m., documented that Resident #1 had remained alert during this period of time while she had been receiving, in error, these excess doses of KCL 40 mEq. However, a Laboratory Report for Resident #1, with a draw date and time of [DATE] at 4:30 a.m., which was approximately the same time the resident received the final dose of KCL, documented the results of a BMP laboratory test which indicated that the resident's potassium level was critically high at 8.2 mmol/L (Reference Range, 3.5 - 5 mmol/L). A notation on this Laboratory Report documented that this ""Critical Value"" had been called to a nursing facility nurse on [DATE] at 12:30 p.m.. A subsequent Resident Progress Notes entry of [DATE] at 2:00 p.m. documented that the nurse had been summoned to the room of Resident #1 by a certified nursing assistant, and that the resident was observed by the nurse to be non-responding to verbal stimuli, and to have no respirations, no blood pressure, and no pulse. A Resident Progress Notes entry of [DATE] at 7:20 p.m. documented that the body of Resident #1 had been released to the funeral home. During an interview conducted on [DATE] at 9:00 a.m. with the Director of Nursing (DON), the DON acknowledged the medication error involving potassium drug therapy for Resident #1. During an interview with Resident #1's attending physician conducted on [DATE] at 9:50 a.m., the physician stated that she had actually been present in the facility when the critical potassium laboratory value report was called to the facility. The physician stated she had then gone to examine the resident and had assessed the resident to be unresponsive. The physician stated she had called the resident's family to notify them of the resident's high potassium level, at which time the family member stated she would call the physician back. The physician stated that before the family member returned the call, the resident had expired. The physician stated that this medication error involving the administration of potassium had been a contributing factor in the resident's death. Based on the above, the facility failed to administer KCL 40 mEq every 4 hours for 2 doses to Resident #1 as ordered by the physician, but rather administered KCL 40 mEq every 4 hours for a total of six (6) doses, in error. The resident was subsequently determined to have a critically elevated potassium level of 8.2 mmol/L, became unresponsive and died . 2. Record review of Resident #2 revealed an entry on the [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. A Resident Progress Notes entry of [DATE] at 10:30 a.m. documented that the resident's [MEDICATION NAME] was supplied by the family. Review of the National Library of Medicine, National Institutes of Health reference for [MEDICATION NAME] revealed that the medication is used to treat certain types of [MEDICAL CONDITION] by blocking [MEDICAL CONDITION] cells from multiplying. The [DATE] MR for Resident #2 indicated that the resident was to receive a [MEDICATION NAME] 150 mg. capsule twice a day via gastrostomy tube at 10:00 a.m. and 10:00 p.m. for the [DIAGNOSES REDACTED]. A [DATE] entry by the evening nurse in the Nurse's Medication Notes Section of this MR documented that this medication was not available at that time, and that the family would bring the medication in the following day. However, further record review conducted on [DATE] revealed no evidence to indicate that the resident had received additional doses of [MEDICATION NAME] at that time, even though the order specifying administration of the drug remained current. There was also no evidence to indicate that the facility had made additional efforts to obtain the resident's [MEDICATION NAME] for administration, nor was there evidence to indicate the attending physician had been notified that the resident had missed multiple doses of [MEDICAL CONDITION] medication. During an interview on [DATE] at 11:20 a.m., the DON stated she had no knowledge that the resident's [MEDICATION NAME] had not been administered as the physician ordered. The DON reviewed the MR at that time and acknowledged that the medication had not been given as ordered. The DON obtained the package container for the resident's [MEDICATION NAME], and confirmed that it was empty and that there was no medication available. During an interview conducted on [DATE] at at 9:40 a.m. with the attending physician, the physician indicated she had no knowledge that Resident #2 was not receiving the ordered medication [MEDICATION NAME]. The physician stated that the medication should be given as ordered, and if unavailable, the physician should be notified. Record review revealed that after the physician's interview referenced above, an order was written to hold Resident #2's [MEDICATION NAME] until available. Evidence thus indicated that Resident #2 missed a minimum of five (5) doses of [MEDICATION NAME], ordered to be given twice daily, due to the medication not being available, during which time the facility failed to notify the physician for further instructions. It was determined that the immediate jeopardy was removed as of [DATE], by which time the facility had completed the following actions. Beginning on [DATE], and continuing through [DATE], the following corrective interventions were being taken by the facility to ensure accurate medication administration: I. On [DATE], four (4) registered nurses and fifteen (15) licensed practical nurses received inservice education on medication errors and verbal/oral telephone orders. The education included face-to-face training on the validation of telephone orders; monitoring of laboratory values; medication effects of high risk medications such as Potassium, [MEDICATION NAME], and Insulin; clarification of medication orders with the physician and/or nurse practitioner; signs of hypo/[MEDICAL CONDITION]; and the policy and procedure for verbal/telephone orders, hand written orders, written transfer orders or faxed orders. II. On [DATE], a process was begun by which newly hired licensed nurses will be educated during the orientation process that will be conducted by the DON, Assistant Director of Nursing (ADON), and/or Staff Development Coordinator. III. On [DATE], the licensed nurse who transcribed the KCL order for Resident #1 was removed from the work schedule and suspended pending the results of investigation by the Georgia Board of Nursing. IV. On [DATE], the Performance Improvement Committee met to address the adverse event and discuss appropriate interventions. The committee consisted of the Administrator, Medical Director, DON, the Admissions Coordinator and the Corporate Risk Manager. V. On [DATE], a process was begun by which new admissions, re-admissions and revised medication orders will be reviewed by the admitting licensed nurse and a second verification will be performed by a registered nurse to assure validity and accuracy of medication orders. The DON, ADON, and Unit Managers will perform a third verification of medication orders to assure validity and accuracy in the Clinical Morning Meeting at least five (5) times a week. The Nursing Supervisor and/or Charge Nurses will be responsible for reviewing and validating new admissions, re-admissions, and revised orders on the weekend. Negative findings through this process will be corrected immediately through physician and/or nurse practitioner notification, and discontinuance of inaccurate medication orders will occur immediately. The institution of the correct transcribed medication order to the telephone order sheet, MR and medical record will be documented as outlined by the policy and procedures. A Medication Variance Report will be completed by the Unit Managers and/or the DON or ADON when medication inaccuracies are identified through this newly adopted, systematic change. This process will be on-going. VI. On [DATE], a process was enacted by which the DON, and/or ADON, and/or Unit Managers will audit new admissions, re-admissions and medication orders in daily clinical review. The results of these audits will be analyzed and reviewed at the facility's monthly Performance Improvement Committee meetings for six months. A subsequent plan will be devised and implemented as needed. This process will be ongoing. VII. On [DATE], a complete review and audit of all resident clinical records was completed by the DON, ADON, and Unit Managers. This review and audit included comparing physicians' orders and telephone orders to the transcribed medication orders on the MRs. VIII. On [DATE], two (2) registered nurses and twenty-seven (27) licensed practical nurses received inservice education on medication errors and verbal/written/oral telephone orders, as described above. IX. On [DATE], ten (10) of the licensed practical nurses and three (3) of the registered nurses who had originally received the [DATE] inservice training referenced above, and four (4) of the licensed practical nurses and one (1) registered nurse who had received the [DATE] inservice training referenced above, received additional inservice training on medication errors, medication transcription, medication administration records, and treatment administration records. In addition, two (2) licensed practical nurses and two (2) registered nurses, with no documented attendance in either of the previous inservice training sessions, received training on this date. Based on these corrective action plans which had been developed and implemented by the facility as outlined above, the immediacy of the deficient practice had been removed on [DATE]. However, the effectiveness of these corrective action plans could not be fully assessed to ensure ongoing application and completion. On [DATE], four (4) registered nurses and fifteen (15) licensed practical nurses received inservice education including medication errors and verbal/oral telephone orders, and on [DATE], two (2) registered nurses and twenty-seven (27) licensed practical nurses received this inservice education. However, on [DATE], ten (10) of the licensed practical nurses and three (3) of the registered nurses who had originally received the [DATE] inservice training referenced above, four (4) of the licensed practical nurses and one (1) registered nurse who had received the [DATE] inservice training referenced above, and two (2) licensed practical nurses and two (2) registered nurses with no documented attendance in either of the previous inservice training sessions, received additional or initial inservice training on medication errors, medication transcription, medication administration records, and treatment administration records. Also, on [DATE], a process was enacted by which the DON, and/or ADON, and/or Unit Managers will audit new admissions, re-admissions and medication orders in daily clinical review, the results of which will be analyzed and reviewed at the facility's monthly Performance Improvement Committee meetings for six months. However, the first meeting of the Performance Improvement Committee to occur after the implementation of the new monitoring procedures and chart audit procedure to begin the process of analyzing the audit did not occur until [DATE], and the committee will not meet again for a month. Therefore, the noncompliance continues, with the scope and severity level of the deficiency decreased to the ""D"" level.",2015-05-01
9723,KINDRED TRANSITIONAL CARE AND REHAB - LAFAYETTE,115360,110 BRANDYWINE BOULEVARD,FAYETTEVILLE,GA,30214,2012-01-26,514,J,1,0,5SCS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, hospital Medication Profile review, facility staff interview, and attending physician interview, the facility failed to ensure that the clinical records of four (4) residents (#s 1, 2, 6, and 7), on the total survey sample of sixteen (16) residents, were accurate, related to the transcription of a physician's orders [REDACTED]. Specifically, Resident #1 had a physician's orders [REDACTED]. This resulted in the resident receiving four (4) additional doses of the drug in error, and the resident subsequently died after a laboratory test indicated a critical potassium level. Based on the above, it was determined that the facility's failure to accurately transcribe the order, and failure to thus administer KCL as ordered by the physician, had caused serious harm to, and contributed to the death of, Resident #1. It was therefore determined that the facility's noncompliance with one or more requirements had resulted in an immediate and serious threat to resident health and safety which was identified to have existed on [DATE] and continued through [DATE], at which time a plan was implemented by the facility to remove the immediate jeopardy situation as of [DATE]. The facility's Administrator and Director of Nursing were informed of this immediate jeopardy on [DATE] at 1:55 p.m. Findings include: 1. Cross refer to F329 and F333, example 1, for more information regarding Resident #1. Record review for Resident #1 revealed a Physician's Telephone Orders sheet dated [DATE] which specified an order to administer KCL forty (40) mEq. by mouth every four (4) hours times two (2) doses. However, review of the [DATE] Medication Record (MR) for Resident #1 revealed that the physician's orders [REDACTED]. Further review of this MR revealed documentation indicating that Resident #1 received 40 mEq. doses of KCL at 9:00 a.m., 1:00 p.m., 5:00 p.m., and 9:00 p.m. on [DATE], and at 1:00 a.m. and 5:00 a.m. on [DATE]. Thus, Resident #1 received a total of six (6) 40 mEq. doses of KCL, instead of two (2) doses as ordered by the physician. A Laboratory Report for Resident #1 of [DATE] at 4:30 a.m. documented the results of a BMP laboratory test which indicated that the resident's potassium level was critically high at 8.2 millimoles per liter (mmol/L) (Reference Range, 3.5 - 5 mmol/L). A subsequent Resident Progress Notes entry of [DATE] at 2:00 p.m. documented that the nurse had been summoned to the room of Resident #1 and that the resident was observed not to respond to verbal stimuli, and to have no respirations, no blood pressure, and no pulse. During an interview with the Resident #1's attending physician conducted on [DATE] at 9:50 a.m., the physician stated that this medication error involving the administration of potassium had been a contributing factor in the resident's death. 2. Record review of Resident #2 revealed Physician's Telephone Orders sheet dated [DATE] with an order for [REDACTED]. However, during observations of Resident #2 conducted on [DATE] at 9:40 a.m., 10:15 a.m., 11:25 a.m. and 3:15 p.m., and on [DATE] at 9:00 a.m. and 10:55 a.m., the oxygen concentrator flow meter was set on four (4) LPM. Review of the [DATE] MR revealed that nursing staff had initialed, in error, that Resident #2's oxygen concentrator was flowing at two (2) LPM during the 7:00 a.m.-3:00 p.m. shift of [DATE], even though during the observations referenced above the resident's oxygen was observed to be at four (4) LPM. 3. Record review for Resident #7 revealed a hospital Medication Profile sheet dated [DATE] which documented that the resident was transferred to the nursing facility with admission orders [REDACTED]. However, review of a nursing facility Physician's Telephone Orders sheet for Resident #7 dated [DATE], and signed by Registered Nurse ""HH"", revealed that the transfer order specifying that a [MEDICATION NAME] be completed on [DATE] had been transcribed to specify only that a [MEDICATION NAME] be done, but did not specify the date the laboratory test was to be completed. This physician's orders [REDACTED]. During an interview conducted on [DATE] at 2:55 p.m. with Licensed Practical Nurses ""AA"" and ""BB"", these nurses acknowledged that the order written by Nurse ""HH"" should have been clarified. 4. Record review for Resident #6 revealed a Physician's Telephone Orders sheet dated [DATE] indicating to discontinue [MEDICATION NAME], and to continue [MEDICATION NAME] sulfate. However, there was no indication in this order of the dose, frequency of administration, or route of administration for [MEDICATION NAME] sulfate. It was determined that the immediate jeopardy was removed as of [DATE], by which time the facility had completed the following actions. Beginning on [DATE], and continuing through [DATE], the following corrective interventions were being taken by the facility to ensure accurate medication administration: I. On [DATE], four (4) registered nurses and fifteen (15) licensed practical nurses received inservice education on medication errors and verbal/oral telephone orders. The education included face-to-face training on the validation of telephone orders; monitoring of laboratory values; medication effects of high risk medications such as Potassium, [MEDICATION NAME], and Insulin; clarification of medication orders with the physician and/or nurse practitioner; signs of hypo/[MEDICAL CONDITION]; and the policy and procedure for verbal/telephone orders, hand written orders, written transfer orders or faxed orders. II. On [DATE], a process was begun by which newly hired licensed nurses will be educated during the orientation process that will be conducted by the Director Of Nursing (DON), Assistant Director of Nursing (ADON), and/or Staff Development Coordinator. III. On [DATE], the licensed nurse who transcribed the KCL order for Resident #1 was removed from the work schedule and suspended pending the results of investigation by the Georgia Board of Nursing. IV. On [DATE], the Performance Improvement Committee met to address the adverse event and discuss appropriate interventions. The committee consisted of the Administrator, Medical Director, DON, the Admissions Coordinator and the Corporate Risk Manager. V. On [DATE], a process was begun by which new admissions, re-admissions and revised medication orders will be reviewed by the admitting licensed nurse and a second verification will be performed by a registered nurse to assure validity and accuracy of medication orders. The DON, ADON, and Unit Managers will perform a third verification of medication orders to assure validity and accuracy in the Clinical Morning Meeting at least five (5) times a week. The Nursing Supervisor and/or Charge Nurses will be responsible for reviewing and validating new admissions, re-admissions, and revised orders on the weekend. Negative findings through this process will be corrected immediately through physician and/or nurse practitioner notification, and discontinuance of inaccurate medication orders will occur immediately. The institution of the correct transcribed medication order to the telephone order sheet, MR and medical record will be documented as outline by the policy and procedures. A Medication Variance Report will be completed by the Unit Managers and/or the DON or ADON when medication inaccuracies are identified through this newly adopted, systematic change. This process will be on-going. VI. On [DATE], a process was enacted by which the DON, and/or ADON, and/or Unit Managers will audit new admissions, re-admissions and medication orders in daily clinical review. The results of these audits will be analyzed and reviewed at the facility's monthly Performance Improvement Committee meetings for six months. A subsequent plan will be devised and implemented as needed. This process will be ongoing. VII. On [DATE], a complete review and audit of all resident clinical records was completed by the DON, ADON, and Unit Managers. This review and audit included comparing physicians' orders and telephone orders to the transcribed medication orders on the MRs. VIII. On [DATE], two (2) registered nurses and twenty-seven (27) licensed practical nurses received inservice education on medication errors and verbal/written/oral telephone orders, as above. IX. On [DATE], ten (10) of the licensed practical nurses and three (3) of the registered nurses who had originally received the [DATE] inservice training referenced above, and four (4) of the licensed practical nurses and one (1) registered nurse who had received the [DATE] inservice training referenced above, received additional inservice training on medication errors, medication transcription, medication administration records, and treatment administration records. In addition, two (2) licensed practical nurses and two (2) registered nurses, with no documented attendance in either of the previous inservice training sessions, received training on this date. Based on these corrective action plans which had been developed and implemented by the facility as outlined above, the immediacy of the deficient practice had been removed on [DATE]. However, the effectiveness of these corrective action plans could not be fully assessed to ensure ongoing application and completion. On [DATE], four (4) registered nurses and fifteen (15) licensed practical nurses received inservice education including medication errors and verbal/oral telephone orders, and on [DATE], two (2) registered nurses and twenty-seven (27) licensed practical nurses received this inservice education. However, on [DATE], ten (10) of the licensed practical nurses and three (3) of the registered nurses who had originally received the [DATE] inservice training referenced above, four (4) of the licensed practical nurses and one (1) registered nurse who had received the [DATE] inservice training referenced above, and two (2) licensed practical nurses and two (2) registered nurses with no documented attendance in either of the previous inservice training sessions, received additional or initial inservice training on medication errors, medication transcription, medication administration records, and treatment administration records. Also, on [DATE], a process was enacted by which the DON, and/or ADON, and/or Unit Managers will audit new admissions, re-admissions and medication orders in daily clinical review, the results of which will be analyzed and reviewed at the facility's monthly Performance Improvement Committee meetings for six months. However, the first meeting of the Performance Improvement Committee to occur after the implementation of the new monitoring procedures and chart audit procedure to begin the process of analyzing the audit did not occur until on [DATE], and the committee will not meet again for a month. Therefore, the noncompliance continues, with the scope and severity level of the deficiency decreased to the ""D"" level.",2015-05-01