cms_GA: 6787
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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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 6787 | MAGNOLIA MANOR OF ST SIMONS REHAB & NURSING CENTER | 115582 | 2255 FREDERICA ROAD | SAINT SIMONS ISLAND | GA | 31522 | 2013-02-14 | 314 | G | 0 | 1 | NIB111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and staff interviews, it was determined that the facility failed to address signs of pain and provide pain management during the provision of pressure sore treatment for one resident (#112), to notify the physician about the registered dietician's recommendations to promote healing of a pressure sore for one resident (#140), and failed to follow up with the physician timely about the status of an infected pressure sore for one resident (#133) of two of four active residents with pressure sores and one closed record with a pressure sore from a total sample of 38 residents. This failure resulted in actual harm that was not immediate jeopardy for resident #112. Findings include: 1. Resident #112 was admitted into the facility in September of 2011 with [DIAGNOSES REDACTED]. Review of the documentation on the Licensed Nurse Skin Assessments dated September of 2012 revealed that resident #112 had no wounds/pressure ulcers. Licensed nursing staff documented on the October, 2012 skin assessment that the resident had red areas in his/her groin and small open areas. On the November 26, 2012 skin assessment, the licensed nurse documented that there was a black area on the right heel and treatment in progress to the scrotum folds. On January 23, 2013 the nurse documented that resident #112 had deep tissue injury on the right heel. There was a care plan, updated on 11/21/12, to address his/her alteration in skin integrity/pressure ulcer. Pressure ulcer to right medial heel (Deep Tissue Injury). There was an intervention to observe for pain and treat as ordered. The goal included to reduce pain and discomfort. However, during an observation of pressure ulcer wound care and care to the ulcers in the resident's groin area on 02/12/13 at 2:28 p.m., the resident cried out in pain but, the nurse failed to intervene and treat the pain. During an observation of pressure ulcer wound care and care to ulcers in the resident's groin area on 02/12/13 at 2:28 p.m., when licensed nurse FF touched the resident's right heel pressure ulcer to clean it, the resident cried out in pain and jerked his/her right leg back from her. Resident #112 cried out three times during the heel ulcer measurements and application of the ordered [MEDICATION NAME]. At that time, nurse FF said that Resident #112 usually complained of pain during the procedure but, not after it. The nurse said that resident #112 had a 1.0 x 0.2 centimeter (cm) opening in his/her left groin fold and a 0.2 cm x 0.2 cm opening in the right groin fold. Resident #112 cried out in pain during the treatment procedures. The resident said expletives and told the nurse that she did not know she was doing. Immediately after the pressure sore treatments were done, nurse FF said that resident #112 commonly called out during the wound care procedure and was medicated. Review of the resident's Nurse's Notes and Medication Administration Records (MARs) revealed no documentation that resident #112 was pre-medicated before wound care was performed to his/her heels or groin area. There was no documentation of pain medication having been given related to the pressure ulcer wound care. On 2/13/13 at 9:45 a.m., nurse FF stated that she had asked the medication nurse on 2/12/13 to pre-medicate the resident before wound care was done. However, nurse FF said that she did not check to ensure that the resident had been given medication prior to her doing the wound cares. Nurse FF acknowledged that the resident had cried out in pain and jerked his/her leg during treatment and that she could have stopped the treatment. There was a physician's orders [REDACTED]. However, nurse FF also acknowledged that she had used normal saline to clean the wound bed on resident #112's groin and not soap and water as ordered by the physician. Nurse FF said that she was responsible to update the care plan about the pressure ulcer on the resident's right heel to reflect the current treatment and not the initialed treatment dated November 2012. In an interview on 2/13/13 at 7:47 a.m., medication nurse DD stated that, sometimes resident #112 could tell you when he/she was in pain. Nurse DD said that, if the resident was sitting up at the nurse's station and hollered out, he/she could tell nurse DD if his/her foot was hurting and could be repositioned and express whether that intervention helped. Nurse DD said that resident #112 was not medicated for pain before the wound care was done on him/her on 02/12/13. She said that resident #112 had not complained about pain yesterday before the procedure but, if the resident had complained of pain, nurse DD said that she/he would have given the 'as needed' (prn) medication. Nurse DD said that she did the wound care treatments if the treatment nurse was off. She said that the last time she did the wound care for resident #112, he/she did not cry out in pain. Review of the February 2013 physician's orders [REDACTED]. During an interview on 2/13/13 at 10:55 a.m., the facility's Medical Director said that he did not want resident #112 to be uncomfortable during dressing changes and it sounded like he/she was (uncomfortable) yesterday. The physician said that resident #112 did curse at staff sometimes whether they were touching him/her or not but, it sounded like he/she was having pain during the treatment yesterday. The physician said that he would address resident #112's pain management. The physician said that he was not aware of any correspondence from the facility by phone or fax related to resident #112's pain management yesterday or today. Review of the Message to the Physician that was faxed by the facility on 02/12/13 at 6:30 p.m., and returned to the facility on [DATE] at 7:57 p.m., revealed that the treatment nurse had notified the physician about the open area on the outer edge of the eschar cap on the resident's right heel. However, there was no documentation that the nurse notified the physician about resident #112's level of pain experienced during the dressing change procedure that day. The physician response noted to change the type of dressing from [MEDICATION NAME] open to air to a foam dressing. During an interview on 2/13/13 at 1:00 p.m., the Director of Nursing (DON) stated that the nurse should have stopped the wound care when Resident #112 cried out in pain. 2. Resident #140 was admitted with an unstageable pressure ulcer on his/her sacrum. During a hospitalized from [DATE] to 1/03/13 for pneumonia and [MEDICAL CONDITION], the sacral pressure ulcer was debrided and [DEVICE] treatments begun. On 1/27/13, the facility's Registered Dietician documented a recommendation for restoring MVI (multivitamin) every day, 500 milligrams (mg) of Vitamin C twice a day, and 220 mg of Zinc every day for 30 days, and one packet of Juven in 60 milliliters (ml) of water for 90 days to promote wound healing. However, there was no evidence that the physician was aware of those recommendations. During an interview on 2/14/13 at 8:30 a.m., Registered Nurse BB confirmed that there was no evidence that the 1/27/13 RD recommendations had been communicated to the physician. After surveyor inquiry, the Director of Nursing provided a Physician Communication Form dated 1/27/13 for the physician to consider the RD recommendations. However, the documentation to implement those recommendations was not signed by the Nurse Practitioner until 2/14/13. There was no evidence that the physician had been made aware of those recommendations or that nursing staff had followed up on the 1/27/13 Physician Communication Form until 2/14/13. 3. Resident #133 (closed record) was admitted on [DATE] with [DIAGNOSES REDACTED]. The resident was admitted with a full length knee extension brace/immobilizer on his/her left leg to prevent knee flexion and had a physician's orders [REDACTED]. According to the 10/18/12 Treatment Record, the resident developed a 3.2 centimeter (cm) by 4 cm., closed, deep tissue injury on the plantar aspect of his/her left foot that was caused by the left leg immobilizer. The physician was notified, the immobilizer was cut to prevent pressure and the pressure sore was treated as ordered. On 11/02/12, a communication was faxed to the resident's physician notifying him that the now open pressure sore on the plantar aspect of the resident's left foot had a moderate amount of greenish drainage and that the surrounding tissue was red and [MEDICAL CONDITION]. On 11/03/12, the physician faxed the facility with a request for the resident's medication list. However, there was no indication that licensed/registered nursing staff had followed up with the physician about the greenish drainage from the resident's pressure sore until 10 days later, on 11/12/12, when the physician's family nurse practitioner (FNP) assessed the resident and noted a thick, yellow purulent drainage coming from the pressure sore with redness and swelling of the surrounding skin. At that time, the FNP ordered a wound culture to be obtained and for licensed nursing staff to administer 500 milligrams of [MEDICATION NAME] (an antibiotic) to the resident every day. The resident was discharged home on[DATE]. The pressure sore at that time had decreased in size, had pink granulation tissue, light non-purulent drainage and the surrounding skin was not red or [MEDICAL CONDITION]. | 2017-10-01 |