cms_GA: 3324
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 3324 | FORT VALLEY HEALTH AND REHAB | 115651 | 604 BLUEBIRD BOULEVARD | FORT VALLEY | GA | 31030 | 2018-07-25 | 686 | E | 1 | 0 | 75FB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews and record review, the facility failed to ensure that pressure ulcer treatment was provided as ordered for three residents (A, #2 and #3) from a total sample of eight residents. Findings include: During interviews on 7/24/18 at 10:45 a.m. and 2:40 p.m. the wound treatment Licensed Practical Nurse (LPN) stated that she provided wound treatments during the week (Monday through Friday) and the Registered Nurse (RN) supervisor provided wound treatments on the weekends. She also stated that she had noticed at times that treatments were not completed as ordered over the weekends. During an interview on 7/24/18 at 3:38 p.m., RN weekend supervisor AA stated that she was supposed to provide wound treatments, as ordered, and did so, if she was only supervising. However, she stated that she was unable to if she was also pulled to administer medications. She stated that if she was pulled to administer medications, she would also try and provide treatments to those residents assigned to her, but always had one or two that did not get completed. 1. Record review revealed that resident (R) A was admitted to the facility on [DATE] with a stage IV pressure ulcer to the sacrum. There was a care plan problem in place, since 1/8/18, to address the pressure ulcer that included an intervention for licensed nursing staff to administer treatments as ordered. The current physician ordered pressure ulcer treatment, since 5/11/18, was for licensed nursing staff to cleanse the pressure ulcer to the sacrum with normal saline or wound cleanser, apply Hydrogel, cover with an Alginate wound dressing and cover with a dry dressing daily and as needed. However, a review of the clinical record revealed no evidence that the pressure ulcer treatment had been provided, as ordered, for one weekend day in (MONTH) (5/20/18), six days in (MONTH) (6/2, 6/3, 610, 6/16, 6/17 and 6/23/18), and one day in (MONTH) (7/15/18). During an interview on 7/24/18 at 12:10 p.m. Resident (R) A stated that his pressure ulcer treatment did not always get changed on the weekends. He stated that the facility did not have a wound treatment nurse on the weekends so the nurses had to decide on who was going to do treatments, and then it still did not get done. Observation of wound care on 7/24/18 at 4:05 p.m. with the Treatment nurse revealed the resident had a small open pinpoint sized circular pressure ulcer to the sacrum. The wound was surrounded by healed, pink scar tissue indicated the wound was previously very large and has healed unevenly. The wound treatment was completed as ordered with no concerns. Review of the weekly skin assessment and measurements revealed the pressure ulcer was improving. 2. R #2 had a stage two pressure ulcer to the left ankle since at least 11/30/17. A review of the (MONTH) (YEAR) Treatment Administration Record (TAR) revealed a physician's orders [REDACTED]. However, there was no evidence in the clinical record that the treatment was provided as ordered on four weekend days in (MONTH) (6/2/18, 6/3/18, 6/9/18 and 6/10/18). On 6/15/18 the treatment order to the left ankle was changed to cleanse the left outer ankle with normal saline, wound cleanser or sterile water, pat dry with gauze, apply Fibrocal or equivalent collagen and cover with bordered gauze or dry Kerlix and secure with tape once daily. However, there was no evidence the treatment was provided as ordered on weekend days 6/16, 6/17, 6/23, 7/15, 7/21 and 7/22/18. The resident refused for the surveyor to observe wound care. Review of the weekly wound assessment and measurements revealed the resident has had the pressure ulcer left ankle since (YEAR). The wound will improve then decline and improve again. Currently the wound is a Stage II PS measuring 2 centimeters (cm) by 1.5 cm by 0.1 cm in deep. Review of the right ankle weekly assessment and measurements revealed the would had resolved on 5/25/18. 3. R#3 had a stage two pressure ulcer to the sacrum since 6/11/18. The current physician's orders [REDACTED]. However, a review of the clinical record revealed no evidence that the pressure ulcer (PS) treatment had been provided as ordered for three weekend days in (MONTH) (6/16, 6/17, and 6/23/18) and three weekend days in (MONTH) (7/15, 7/21 and 7/22/18). A review of the (MONTH) (YEAR) TAR revealed a physician's orders [REDACTED]. However, there was no evidence in the clinical record that the treatment was provided as ordered on 6/16, 6/17 and 6/23/18. The pressure ulcer to the left heel healed on 6/25/18. The treatment order was changed to cleanse the right heel with normal saline or wound cleanser, pat dry with gauze, apply Sureprep or equivalent skin barrier wipe, dry dressing, and wrap with Kerlix and secure with tape daily. However, the were no evidence in the clinical record that the treatment was provided as ordered on 7/15, 7/21 and 7/22/18. Observation on 7/24/18 at 2:45 p.m. of the resident's PS treatment with the treatment nurse revealed the resident has an open PS to the sacrum. The wound bed was beefy red, had no signs of infection, was clean and odor free. The would measured 2.4 cm by 4.0 cm. The treatment nurse stated the resident was on Hospice services and had developed a pressure ulcer to the left heel. Review of the weekly skin assessments and measurements revealed the wounds were improving and decreasing in size. During an interview on 7/25/18 at 1:34 p.m., LPN BB confirmed that she was assigned to resident A and #3 on 6/16/18 and 6/17/18 but did not remember if she provided a wound treatment or not. She stated that she does not normally provide wound treatments, including on the weekends, and had not been trained to provide wound treatments. She further stated that the nurse supervisor provided wound treatments on the weekends. When the supervisor was also assigned to administer medications, she did not know who provided wound treatments because she did not have time to administer medications and provide wound treatments to the residents she was assigned. She also stated that she had not been instructed by the nurse supervisor to provide wound treatments, if the supervisor was also administering medications. LPN BB stated that she had changed resident A's wound treatment before, when it has been soiled, but not routinely. During an interview on 7/25/18 at 1:50 p.m. LPN CC confirmed that she did not provide a wound treatment for [REDACTED]. She stated that when she works on the weekends she had never been instructed to provide wound treatments for her assigned residents, unless a dressing came off or was soiled. She stated that the RN supervisor would provide the wound treatments on the weekends. LPN CC also stated that when the RN supervisor also had to administer medications, she, LPN CC had not been instructed to provide wound treatments to the residents she was also assigned to administer medications to. | 2020-09-01 |