| 10365 |
FAIRBURN HEALTH CARE CTR, INC |
115298 |
178 WEST CAMPBELLTON STREET |
FAIRBURN |
GA |
30213 |
2009-03-03 |
309 |
E |
1 |
0 |
TK3H11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to do Accuchecks in accordance with physicians' orders for six (6) residents (#s 1, 2, 3, 4, 5 and 6) out of eleven (11) sampled residents. Findings include: 1. Record review for Resident #1 revealed that the Medication Record (MR) documented that the resident had [DIAGNOSES REDACTED]. The resident had a current physician's orders [REDACTED]. The resident also had a current physician's orders [REDACTED]. However, review of the resident's MR for the month of November 2008 revealed no evidence to indicate that Accuchecks were done as ordered and scheduled on 11/08/2008 at 6:30 a.m. and on 11/13/2008 at 4:30 p.m. Review of the November 2008 and December 2008 MR revealed that for the dates of 11/25/2008, 12/01/2008, 12/03/2008 and 12/24/2008, the nurse had initialed the 6:30 a.m. Accuchecks on the MR, circled the initials, and documented in the Nurse's Medication Notes of the MR that the Accuchecks were not done because no strips were available. 2. Record review for Resident #2 revealed that the MR documented that the resident had [DIAGNOSES REDACTED]. The resident had a current physician's orders [REDACTED]. However, review of the MR for the month of December 2008 revealed no evidence to indicate that Accuchecks were done as ordered and scheduled for the dates of 12/21/2008 and 12/26/2008 at 11:30 a.m., and for 12/10/2008 and 12/16/2008 for at 9:00 p.m. Additional review of this MR revealed that for the dates of 12/02/2008 and 12/24/2008, the nurse had initialed the 6:30 a.m. Accuchecks on the MR, circled the initials, and documented in the Nurse's Medication Notes of the MR that the Accuchecks were not done because no strips were available. 3. Record review for Resident # 3 revealed a current physician's orders [REDACTED]. However, review of the November and December 2008 MRs revealed no evidence to indicate that Accuchecks were done as ordered and scheduled on 11/08/2008 and 12/22/2008 at 6:30 a.m., or on 11/14/2008 and 11/19/2008 at 4:30 p.m. Additional review of these MRs revealed that for the dates of 11/26/2008, 12/02/2008, and 12/03/2008, the nurse had initialed the 6:30 a.m. Accuchecks on the MR, circled the initials, and documented in the Nurse's Medication Notes of the MR that the Accuchecks were not done because no strips were available. 4. Record review for Resident # 4 revealed a current physician's orders [REDACTED]. However, review of the December 2008 MR revealed no evidence to indicate that the Accucheck was done as ordered and scheduled on 12/28/2008 at 9:00 p.m. Further review of this MR revealed that for the dates of 12/23/2008 and 12/24/2008, the nurse had initialed the 11:30 a.m. Accuchecks, circled the initials, and documented in the Nurse's Medication Notes of the MR that the Accuchecks were not done because there were no strips available. 5. Record review for Resident #5 revealed that the MR documented [DIAGNOSES REDACTED]. The resident had a current physician's orders [REDACTED]. However, review of the November and December 2008 MRs revealed no evidence to indicate that Accuchecks were done, as ordered and as scheduled, on 11/16/2008, 11/29/2008, 11/30/2008, 12/03/2008, and 12/30/2008 at 4:30 p.m. Further review of the December 2008 MR revealed that for the dates of 12/01/2008 and 12/03/2008, the nurse had initialed the 6:30 a.m. Accuchecks, circled the initials, and documented in the Nurse's Medication Notes of the MR that the Accuchecks were not done because there were no strips available. 6. Record review for Resident # 6 revealed that the MR documented [DIAGNOSES REDACTED]. The resident had a current physician's orders [REDACTED]. However, review of the November and December 2008 MRs revealed no evidence to indicate that Accuchecks were done, as ordered and as scheduled, on 11/16/2008, 11/29/2008, and 12/08/2008 at 4:30 p.m. Further review of the December 2008 MR revealed that for the dates of 12/01/2008 and 12/03/2008, the nurse had initialed the 6:30 a.m. Accuchecks, circled the initials, and documented on the Nurse's Medication Notes that the Accuchecks were not done because there were no strips available. On 01/26/09, at 4:45 p.m., during an interview with the Director of Nursing, the Director of Nursing acknowledged that the Accuchecks referenced above for Residents #1, #2, #3, #4, #5 and #6 were not done as ordered, and further stated she was not aware that these residents did not have the Accuchecks for so many days. |
2014-07-01 |