| 4280 |
SOUTHWELL HEALTH AND REHABILITATION |
115655 |
260 MJ TAYLOR ROAD |
ADEL |
GA |
31620 |
2016-07-01 |
314 |
D |
0 |
1 |
0GTS11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview ,the facility failed to follow physician's wound care orders and failed to notify the resident's physician in a timely manner of wound care recommendations which included treatment with an antibiotic and laboratory test recommendations for one (1) resident (#64) with a stage four pressure ulcer to the sacrum from a total sample of forty two (42) residents. Findings include: Review of resident #64's Quarterly 5/18/16 Minimum Data Set (MDS) assessment revealed in section I the [DIAGNOSES REDACTED]. In addition, in section M, he/she was coded with a ) stage four (4) pressure ulcer. Review of the 3/23/16 Wound Care physician's recommendations revealed the following: stage four (4) pressure ulcer cleanse daily with saline, pack with one half inch plain gauze soaked in [MEDICATION NAME], then cover with [MEDICATION NAME], place a [MEDICATION NAME] border gauze do this twice daily. On 3/24/16 a physician's orders [REDACTED]. ( Clean wound to sacrum with normal saline , pack with [MEDICATION NAME] soaked gauze, cover with [MEDICATION NAME] and [MEDICATION NAME] twice daily (bid) until next visit in one week 4/1/16.) Record review of the (MONTH) Treatment Record Review revealed the 3/24/16 physician's orders [REDACTED]. However, during further review of the Treatment Record it was noted that the wound care was documented as done only once a day on 3/24,3/25, 3/28, 3/29, 3/30 and 3/31/16, instead of twice a day as ordered per physician. During an interview on 6/29/16 at 7:50 a.m. the Wound Care nurse confirmed the documentation on the Treatment Record noted that the dressing change was only done once a day on 3/24/16, 3/25/16,3/28/16,3/29/16,3/30/16 and 3/31/16. The Wound Care nurse further stated that this came to his/her attention on 3/26/16 and 3/27/16. He/she stated that he/she spoke to the Director of Nursing (DON) about the treatment had only been done once a day instead of twice a day as ordered. During an interview on 6/29/16 at 8:05 a.m. the DON confirmed that according to the (MONTH) Treatment Record, the wound care treatment was done daily instead of bid as ordered on 3/ 24/16, 3/25/16, 3/28/16, 3/29/16, 3/30/16 and 3/31/16. He/she further stated he/she was not aware that the treatment was not done as ordered until now. The DON further stated that he/she expected the licensed nursing staff to follow the physician's orders [REDACTED]. Further review of the 3/23/16 Wound Care physician's recommendations also included [MEDICATION NAME] 100 milligram (mg) bid, Glucerna one (1) can three times daily, Complete Metabolic Profile (CMP),Complete Count (CBC) and Pre [MEDICATION NAME] and facsimile the results to the wound care clinic and obtain Fingerstick Blood Sugar(FSBS) daily and send results . Review of the physician's orders [REDACTED]. During an interview on 6/29/16 at 9:06 a.m. and at 9:45 a.m., the DON confirmed the 3/23/16 Wound Care physician's recommendations were not written as physician orders [REDACTED]. The DON stated that recommendations for medication have to be faxed to the resident's physician for approval. The DON stated the recommendations were faxed to the attending physician, but the nurse failed to follow up with the attending physician on 3/24/16. The DON stated he/she would have expected the nurse to have called the resident's physician on 3/24/16 and followed up on the the Wound Care physician's recommendations. During an interview on 6/30/16 at 9:00 a.m. with the ADON , he/she explained the process for communication of recommendations from the Wound Care physician: When the resident returns from the Wound Care clinic the recommendations come back with the resident and are given to the unit nurse who writes the orders for the wound care, if there are laboratory or medication orders, as in this resident's case on 3/23/16, the unit nurse would fax the recommendations to the resident's Physician due to a quick turn around normally and if no response from the resident's physician in a couple of hours he/she would expect the nurse to call the physician and review the recommendations. The ADON stated further that the licensed nursing staff had dropped the ball. |
2020-01-01 |