cms_GA: 10436
Data source: Big Local News · About: big-local-datasette
| rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 10436 | HARALSON NSG & REHAB CENTER | 115431 | 315 FIELD STREET | BREMEN | GA | 30110 | 2009-02-25 | 281 | D | 1 | 0 | HC6L11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interview, resident interview, family interview, and review of The Georgia Practical Nurses Practice Act, the facility failed to administer medications per professional standards and per facility protocol. Problems were identified for three (3) residents ("A", "B" and "C") from a survey sample of eight (8) residents. Findings Include: 1. Record review for Resident "A" revealed a January 2009 Minimum Data Set assessment which indicated that the resident had no problems with either short-term or long-term memory. Record review for Resident "A" also revealed a current physician's orders [REDACTED]. During an observation conducted on 02/25/2009 at 12:50 p.m., Nurse "BB" placed Tylenol tablets in a medication cup, walked to the resident's room, placed the medication cup on the resident's meal tray, and instructed the resident to take the medication when he/she was ready. The nurse was then observed to leave the resident's room before the resident ingested the medication. The resident was observed to take the medication without nurse oversight. During an interview with Resident "A" conducted on 02/25/2009 at 12:55 p.m., the resident confirmed that he/she was given Tylenol for pain and that the nurse left the medication on the meal tray to take when he/she was ready. The resident further stated the nurses never watch her/him take the medication, but rather always trust her/him to take the medicine. During an observation conducted at the time of this interview, the medication cup was observed to be sitting on the meal tray and empty. During an interview conducted on 02/25/2009 at 1:55 p.m., Nurse "BB" acknowledged that she handed Resident "A" the dose of Tylenol referenced above, but did not wait to observe the resident ingest the Tylenol. 2. Record review for Resident "C" revealed a December 2008 Minimum Data Set assessment which indicated that the resident had no short-term or long-term memory problems. During an interview with Resident "C" conducted on 02/25/2009 at 4:45 p.m., the resident stated that on some occasions, some nurses did not watch her/him take medication, often leaving the medications for the resident to take at his/her convenience. 3. During an interview with a family member of Resident "B" conducted on 02/25/2009 at 1:15 p.m., the family member stated that nurses crushed the resident's medication, and then brought the medication in a small cup and gave to the family member during meals to mix with food to give to the resident. The family member stated that the nurses did not observe the resident take the medication, but rather trusted the family member to administer the medication to the resident. During an interview with the Director of Nursing (DON) conducted on 02/25/2009 at 3:00 p.m., the DON stated that all nurses were expected to observe a resident take medication to ensure the medication was consumed. Chapter Two, Part 2.3.2, Standards Related to Licensed Practical/Vocational Nurses, of Article 43-26-30, The Georgia Practical Nurses Practice Act, indicates, in Subpart J-3, that the nurse will administer medications accurately, and indicates in Subpart C that the nurse will provide adequate surveillance and monitoring. | 2014-07-01 |