cms_GA: 10529
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| rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 10529 | PRUITTHEALTH - MACON | 115288 | 2255 ANTHONY ROAD | MACON | GA | 31204 | 2011-01-18 | 314 | G | PDM311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and resident and staff interview, the facility failed to implement recommended interventions in a timely maner for one (1) resident with a high risk for pressure ulcers. from a sample of six (6) resident. This resulted in actual harm for one (1) resident (#1) that was not immediate jeopardy. Findings include: Review of the medical record for this resident revealed that he was admitted on [DATE] with multiple [DIAGNOSES REDACTED]. The resident had a gastrostomy tube in place for tube feeding. Review of the admission body audit form dated 12/24/10 revealed no open areas on the sacrum, hips, buttocks, ankles, feet and heels. There was a reddened area on the buttocks but was documented as blanchable. Review of the weekly skin assessment performed on 01/03/1, ten days after admission to the facility, revealed the following: right plantar foot #2 stage II 1.8 centimeter (cm) x 1.1 cm with blister right plantar foot #1 stage ll 3.1 cm x 3.2 cm with blister right heel stage I 6 cm x 6 cm with no drainage left plantar foot stage II 3 cm x 4.5 cm with blister left heel unstageable 4 cm x 4 cm suspected deep tissue injury left heel unstageable 3.5 cm x 3.5 cm suspected deep tissue injury left ankle#1 0.5 cm x 0.5 cm x < 0.1 cm with granulation tissue, light drainage let ankle #2 unstageable 1 cm x 1 cm suspected deep tissue injury left ankle #3 stage II 1.1 cm x 1 cm left third toe stage I 0 .5 cm x 0..5 cm left buttocks stage II 1 cm x 2 cm x less than 0.1 cm left buttocks stage III irregular shape with granulation tissue with slough no drainage right buttocks #1 stage I 3 cm x 1.5 cm x < 0.1 cm granulation tissue and slough right great toe stage I I cm x 1 cm no drainage left third toe stage I 0 .5 cm x 0.5 cm During an interview with the Licensed Practical Nurse (LPN) "AA" on 01/18/11 at 10:00 a.m. and again at 12:30 p.m. she revealed that she had first assessed the resident on 12/24/10 and on 12/29/10 realized that the resident needed a longer bed for a 74 inch body. Continued interview revealed that even when he sat up in bed at a thirty or a forty-five degree angle his feet pressed against the footboard and created pressure against the balls of his feet. She placed heel boots on his feet but this was not enough to relieve the pressure. Further interview revealed that on 12/29/10 during a "ZAP" meeting, when resident needs are addressed, the LPN requested an extra long mattress, as well as, a low air loss mattress for the resident. Upon return to work, on 01/03/11, from scheduled leave time, the LPN assessed the resident's skin and found pressure blisters on the balls of the feet. The resident was still in the same bed as when he was admitted . There was no evidence that a longer mattress or low air loss mattress had been ordered for this resident. These were obtained on 1/03/11. During an interview with the Director Of Nursing (DON) on 01/18/11 at 12:35 p.m. she acknowledged that the LPN had requested the items first during the meeting on 12/29/10 and then again on 01/03/11. She revealed that she had forgotten to place the order. She did add that all residents in the facility are on pressure relief mattresses although not alternating air mattresses. Observation at 9:30 a.m. on 01/18/11 of the resident revealed the upper extremities were contracted and although the resident was diagnosed as a quadriplegic he had enough mobility to use a wedge call button which was close at hand. Interview at 9:30 on 01/18/11 with the resident revealed orientation to time, place, situation, and self. Continued interview revealed that the blistered areas on the feet had occurred because the bed he/she had previously occupied had a mattress that was too short for the resident's 74 inch frame. About a week after admission, the mattress had been ordered and placed on the bed. Further interview revealed that the staff was very good about turning and positioning him/her about every two hours but occasionally would refuse if he had just been positioned after receiving incontinence care and had no complaints about the staff or the care provided. Observation of the resident's wound care on 01/18/2011 at 9:45 a.m., provided by the treatment nurse LPN "AA" revealed treatments were applied to multiple pressure ulcers. There were nonstageable darkened blister areas observed on both balls of the feet as well as eschar areas on outer ankles of both feet. The resident was positioned on an low air loss mattress. Review of the medical record revealed a physician's orders [REDACTED]. Further review revealed assessments for potential risk for pressure ulcers documented as high. Review of the careplan from time of admission and updates though 01/03/11 were found including the identification of high risk for skin breakdown 12 24/10. Interventions included barrier creams, turning and repositioning, and by 01/03/11 nutritional supplements, positioning and use of devices, heel protectors, an extra long bed frame and low air loss mattress. Interview on 1/18/11 at 1:48 p.m. with the administrator revealed that the DON did not order the items due to a corporate memo dated 12/28/10 indicating that items could not be ordered except on the order day as noted for each facility. The facility was not listed on the memo. She indicated that the order had to placed through the corporate office. The DON did not write the order until 01/03/11 because there was no point in writing the order until it could be filled Review of the contract with the Durable Medical Equipment (DME) company revealed that the company agrees to use its reasonable best efforts to deliver product to the facility within four hours. Interview on 1/18/11 at 2:05 p.m. with the clerk at the DME company revealed the order had been placed on 01/03/11 and delivered by the evening of 01/03/11. | 2014-04-01 |