cms_GA: 262
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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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 262 | ABERCORN REHABILITATION CENTER | 115132 | 11800 ABERCORN STREET | SAVANNAH | GA | 31419 | 2018-11-08 | 694 | D | 0 | 1 | LI3X11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation,staff and resident interview, record review, and review of policy titled Guidelines for preventing Intravenous Catheter-Related Infections the facility failed to get a physicians order for peripheral intravenous (IV) dressing changes, IV catheter flushes, IV site observation or IV catheter needle changes since re-admission to the facility on [DATE] with IV antibiotic orders for one resident (R) (R#60). The sample size was 30 residents. Findings include: Record review revealed R#60 was an [AGE] year old female re-admitted to the facility on [DATE] with a diagnosis' that include [MEDICAL CONDITION], hypertension, pneumonia, and urinary tract infection. The Admission Minimum Data Set ((MDS) dated [DATE] revealed section C-Cognition with a Brief Interview for Mental Status (BIMS) score of 11, indicating moderate impaired cognition. An observation of R#60 made on 11/05/2018 at 12:44 p.m. revealed a peripheral IV located in residents left arm. The dressing covering the IV site was not dated and had blood in the catheter tubing. An observation of R#60 made on 11/06/2018 at 7:50 a.m. revealed resident sitting up in bed, noted the dressing for the peripheral IV in left arm was not dated. Blood was noted in the catheter tubing. An IV pole and pump was noted beside bed. An observation of R#60 made on 11/06/2018 at 4:12 p.m. revealed resident up in a wheelchair in her room, noted the dressing for the peripheral IV in left arm was not dated. Blood was noted in the catheter tubing. Review of R#60 Medication Administration Record [REDACTED]. No order for a peripheral IV flush, IV site monitoring for infection/infiltration/potency, or IV dressing changes noted on MAR for (MONTH) or November's MAR. MAR for (MONTH) (YEAR) indicated resident did not receive the IV antibiotic on 10/28/2018 and 10/29/2018 due to code 9 which indicates other: see nurses notes. The administration box for 10/27/2018 was blank. The MAR for (MONTH) (YEAR) indicated the administration box for 11/1/2018 was blank. The medication was given on 11/2/2018 and 11/3/2018. Review of R#60's Progress Notes revealed a note dated 10/28/2018 at 7:34 a.m., 11/1/2018 at 11:31 a.m., and 11/1/2018 at 11:53 a.m. indicating an alert for a possible drug allergy to the [MEDICATION NAME]. There was no indication the alert was called to the physician or the medication was changed. Further review of the Progress Notes revealed a note dated 10/28/2018 at 12:44 p.m. that the Cefpine Solution was not available and was ordered from the pharmacy. A Progress Note dated 10/29/2018 at 9:03 a.m. revealed the pharmacy sent the wrong medication. A Progress Note dated 10/28/2018 at 21:14 p.m. indicated IV to left AC intact. A Progress Note dated 10/30/2018 at 4:56 a.m. indicated left arm IV site dressing remains dry and intact, IV flushed with 10 cubic centimeter (cc) normal saline (NS). A Progress Note dated 11/2/2018 at 22:06 p.m. indicated resident receiving IV Cefpine for [MEDICAL CONDITION] to sacral region via peripheral line in her left arm. IV patent and flushed with NS before and after medication administration. No adverse reactions noted. A Progress Note dated 11/3/2018 at 15:29 p.m. indicated IV site in right arm is flushed and patent without signs and symptoms of infiltration noted. A Progress Note dated 11/6/2018 at 4:05 a.m. indicated IV site to left arm patent with dressing dry and intact. Review of R#60's care plan revealed resident receiving IV therapy for [MEDICAL CONDITION] to sacral region, with a goal indicating resident will remain free of complications of IV therapy throughout course of treatment. The Care Plan Interventions include dressing changes and IV site changes as ordered (per facility protocol), IV therapy per MD order, monitor IV site for potency, flush as ordered, and observe for signs and symptoms of infection/infiltration and notify MD if needed. Interview on 11/06/2018 at 7:50 a.m. with MM LPN who verified R#60 is no longer on IV medications. Interview on 11/07/2018 at 8:55 a.m. with BB LPN revealed R#60 was no longer on IV medications and was not aware resident has a IV in her arm. She verified according the the residents current orders that there are no orders to flush the IV, change the IV, or to change the IV dressing. She stated she has not had any inservices on medication administration and/or IV administration. She stated she is unsure of the policy and if the IV was a PICC line or a peripheral line. Interview on 11/07/2018 at 10:41 a.m. with R#60 revealed the nurse came in and removed the IV. Resident stated someone came in and removed the IV. She also stated the IV has not been changed or the dressing changed since she has been here. She stated they have not been doing anything to the IV. She stated they had troubles with it and the antibiotic would go in very slow. Interview on 11/08/2018 at 11:05 a.m. with the Director of Nursing (DON) revealed when a resident has an order for [REDACTED].#60 did not have any flush order, order to check IV site or order to change the dressing during treatment or currently. He also stated the IV should have been pulled after the resident finished the antibiotics, he stated the nurse should have called the MD for an order to remove the IV. Review of the facility Policy titled guidelines for preventing Intravenous Catheter-Related Infections without a reference date revealed under the heading of General Guidelines b. proper procedures for the insertion and maintenance of IV catheters. Under the heading of Surveillance indicated observe the insertion site every shift, on admission, and with dressing changes. Observe visually or by palpation through the intact dressing. Under the heading of Catheter Site Dressing Regimens indicated to change initial dressing after placement within 24 hours, monitor the catheter site visually during dressing changes. Under the heading of Replacement of IV Catheters indicated a peripheral short catheter can stay in place no longer than 96 hours, if left in place longer than 96 hours, an facility must obtain a physicians order to keep catheter in place. Remove catheters at the end of treatment if there are no further plans for use of the catheter. Under the heading of Documentation indicated to record the appearance of the insertion site, catheter and dressing in the residents medical record. | 2020-09-01 |