cms_GA: 4287

In collaboration with The Seattle Times, Big Local News is providing full-text nursing home deficiencies from Centers for Medicare & Medicaid Services (CMS). These files contain the full narrative details of each nursing home deficiency cited regulators. The files include deficiencies from Standard Surveys (routine inspections) and from Complaint Surveys. Complete data begins January 2011 (although some earlier inspections do show up). Individual states are provides as CSV files. A very large (4.5GB) national file is also provided as a zipped archive. New data will be updated on a monthly basis. For additional documentation, please see the README.

Data source: Big Local News · About: big-local-datasette

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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
4287 SOUTHWELL HEALTH AND REHABILITATION 115655 260 MJ TAYLOR ROAD ADEL GA 31620 2016-07-01 514 E 0 1 0GTS11 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to maintain accurate clinical records regarding the administration of scheduled Insulin, Sliding Scale Insulin and Fingerstick Blood Sugars for five (5) residents(#38 ,#87,#70, #8 and #104) from a total sample of forty- two (42) residents. Findings include: 1. Review of the (MONTH) (YEAR) physician's orders [REDACTED]. Review of the (MONTH) Medication Administration Record [REDACTED]. The space for licensed nursing staff to document was blank. Further review of the (MONTH) (YEAR) physician's orders [REDACTED]. Review of the (MONTH) MAR indicated [REDACTED]. The space for licensed nursing staff to document was blank. Review of the (MONTH) (YEAR) physician's orders [REDACTED]. Review of the (MONTH) MAR indicated [REDACTED]. The space for licensed nursing staff to document was blank. Further review of the (MONTH) (YEAR) physician's orders [REDACTED]. Review of the (MONTH) MAR indicated [REDACTED]. The space for licensed nursing staff to document was blank. During an interview on 7/1/16 at 12:30 p.m., with the Director of Nursing (DON), he/she stated that on the above dates the [MEDICATION NAME] for resident #87 was not documented as administered by the licensed nursing staff. The DON, further stated that he/she expected the nurses to document their initials on the MARs when medications were administered. 2. Resident #8 had a physician's orders [REDACTED]. obtain fasting blood sugar levels in the morning, three times weekly, on Monday, Wednesday, and Friday. However, a review of the clinical record, including the (MONTH) (YEAR) Medication Administration Records (MAR's) and nurses' notes, revealed that licensed nursing staff did not document the fasting blood sugar level results, that were scheduled to be obtained, on 6/15/16, 6/22/16 and 6/29/16. 3. Resident #84 had a physician's orders [REDACTED]. However, a review of the clinical record, including the MAR's and nurses' notes, revealed that licensed nursing staff did not document the blood sugar level results, that were scheduled to be obtained, on 4/15/16 at 4 p.m., on 4/23/16 at 4 p.m. and on 5/13/16 at 4 p.m 4. Review of resident #38's medical record revealed physician's orders [REDACTED]. If the Finger Stick Blood Sugars (FSBS) are less than 60 use the hypoglycemic protocol, FSBS 61-140 give 0 units, FSBS 141-180 give 1 unit, FSBS 181-240 give 2 units, FSBS 241-300 give 4 units, FSBS 301-400 give 6 units, FSBS greater than 400 give 8 units and notify the physician. Review of the (MONTH) (YEAR) MAR for resident #38 revealed the MAR indicated [REDACTED]. Continued review of the (MONTH) MAR indicated [REDACTED]. Review of the (MONTH) (YEAR) MAR indicated [REDACTED]. m., when the FSBS was 256, and on 04/30/16 at 6:00 a.m., when the FSBS was 166. Review of the (MONTH) (YEAR) MAR indicated [REDACTED]. Continued review of the (MONTH) MAR indicated [REDACTED].m Review of the (MONTH) (YEAR) MAR indicated [REDACTED].m Interview on 06/30/16 at 7:00 p.m., the DON stated that he/she confirmed that licensed nursing staff failed to document FSBS and/or sliding scale insulin amounts on the MARs related to the above dates. The DON stated that he/she expected licensed nursing staff to document the amount of sliding scale insulin given and to document FSBS results on the MAR. 5. Review of the medical record for resident #70 revealed a physician's orders [REDACTED]. For FSBS less than 60 follow the [DIAGNOSES REDACTED] protocol. FSBS 61-140 give 0 units, FSBS 141-180 give 2 units, FSBS 181-240 give 4 units, FSBS 241-300 give 6 units, FSBS 301-400 give 8 units, FSBS greater than 400 give 12 units and call the physician. The resident was also ordered [MEDICATION NAME] Insulin 30 units sub q in the evening. Review of the resident's (MONTH) (YEAR) MAR indicated [REDACTED]. Review of the (MONTH) (YEAR) MAR indicated [REDACTED]. Review of the (MONTH) (YEAR) MAR indicated [REDACTED]. Interview on 06/30/16 at 6:58 p.m. with the DON revealed that the resident's MARs had blanks for the amount of sliding scale insulin administered based on the FSBS results. He/she confirmed that the MAR indicated [REDACTED]. The DON revealed that Licensed Staff is expected to document on the MARs and not to leave blanks. 6. Review of the medical record for resident #104 revealed a physician's orders [REDACTED]. In addition, there was a physician's orders [REDACTED]. Review of the resident's (MONTH) (YEAR) MAR indicated [REDACTED]. On 03/30/16 at 11:00 a.m., the FSBS results were 244 but the amount of sliding scale insulin given was blank and the FSBS results for 8:00 p.m. were also blank. On 03/31/16 at 6:00 a.m., the FSBS results was 193 with amount of sliding scale insulin given was blank. Also, on 3/31/16 the [MEDICATION NAME] dose at 8:00 p.m. was blank. Review of the (MONTH) (YEAR) MAR indicated [REDACTED]. On 04/24/16 at 8:00 p.m., the MAR indicated [REDACTED]. the FSBS results were 245 and on 04/26/16 at 7:00 a.m., the FSBS results were 205 but the amount of sliding scale insulin administered was blank as well as the FSBS results for 4:00 p.m On 4/28/16 at 7:00 a.m., the FSBS result was blank. Review of the (MONTH) (YEAR) MAR indicated [REDACTED]., the FSBS results were blank. Review of the (MONTH) (YEAR) MAR indicated [REDACTED]. On 06/25/16 at 6:00 a.m., the FSBS results was blank. Interview on 06/30/16 at 6:55 p.m. with the DON, he/she stated that the resident's MARs had several blanks for the amount of sliding scale insulin that was to be administered, the administration of the [MEDICATION NAME] and the FSBS results were not recorded. The DON revealed that licensed nursing staff are expected to complete the resident's MARs and not leave blanks. 2020-01-01