cms_GA: 10546
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 |
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
10546 | BRIARCLIFF HAVEN HEALTHCARE AND REHAB CENTER | 115531 | 1000 BRIARCLIFF ROAD | ATLANTA | GA | 30306 | 2010-04-30 | 281 | D | I73X11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to clarify a physician's order related to wound care and failed to follow the facility program related to weekly weights for two (2) residents (#15 and #235) of the sampled thirty-five (35) residents. Findings include: 1. Review of the clinical record for resident (#235) revealed physician's order dated 4/23/10, for [MEDICATION NAME] ointment to be applied topically every day. Review of the "Treatment Administration Record" (TAR) revealed that [MEDICATION NAME] ointment was being applied topically every day but there was no evidence of where the [MEDICATION NAME] ointment was being applied. Observation on 04/29/10 at 2:39 p.m. of wound care for resident #235, performed by Treatment Nurse "HH" revealed that the nurse applied the [MEDICATION NAME] inside the sacral pressure ulcer, the right buttock pressure ulcer and the left buttock pressure ulcer. Interview on 04/30/10 at 10:03 a.m., with Treatment Nurse "HH", revealed that the [MEDICATION NAME] ointment should not have been applied to the inside of the pressure ulcers but should have been applied on the outside of the pressure ulcer areas. The facility failed to clarify the use of the [MEDICATION NAME] ointment. 2. Review of the clinical record for resident #15 revealed the resident was admitted to the facility on [DATE] with a weight of one-hundred-ninety-six (196) pounds (lbs). Review of the weight history revealed that on 12/23/09 the resident weighed 186 lbs., which was a 10 lb. weight loss and/or a five percent (5%) weight loss in two (2) weeks. Further review revealed that the resident continued to lose weight, with the last recorded weight dated 4/6/10 at 170 lbs., thus a total weight loss of 26 lbs in four (4) months. Continued review of the clinical record revealed that on 4/06/2010 the resident was placed on a Weight Loss Risk Alert Program and Medals, a nutritional supplement, four (4) ounces three (3) times a day, then weekly weights for four (4) weeks to track the success or failure of the supplement. Interview on 4/30/2010 at 1:15 p.m. with the Registered Nurse Unit Manager, revealed that the resident had only been weighed once in the month of April, and not the weekly per the Weight Loss Risk Alert program. Review of the "Georgia Registered Profession Nurse Practice Act" revealed that "Practice of nursing as a registered nurse" means to perform for compensation any of the following: -Conducts a comprehensive nursing assessment that is an extensive data collection -Detects faulty or missing patient/client information -Provides appropriate monitoring Review of "The practice of licensed practical nursing" means the provision of care for compensation...which shall include, but not be limited to, the following: (A) Participating in the assessment, planning, implementation, and evaluation of the delivery of health care services | 2014-04-01 |