cms_GA: 71
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 71 | WILLIAM BREMAN JEWISH HOME, THE | 115022 | 3150 HOWELL MILL ROAD N.W. | ATLANTA | GA | 30327 | 2017-03-30 | 314 | D | 0 | 1 | U5BR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, facility policy review, and staff interviews, the facility failed to ensure that one resident (R#64) pressure ulcer measurements were completed weekly from a total sample of 35 residents. Findings include: Review of the Documentation section of the facility's Pressure Ulcer Treatment policy and procedure revealed that following wound care, the wound appearance, including wound bed, edges, and presence of drainage should be documented. All assessment data (i.e., wound bed color, size, drainage, etc.) obtained when inspecting the wound should be documented. Review of R #64's clinical record revealed that he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of his Admission Minimum Data Set ((MDS) dated [DATE] noted that he had one Stage 2 pressure ulcer which was present on admission. Review of an impaired skin integrity care plan developed on 2/24/17 revealed that R #64 had a Stage 2 abrasion to his left buttock. Review of his Braden Scale (a tool used to predict pressure ulcer development) dated 3/10/17 revealed a score of 14 (moderate risk for development of a pressure ulcer). Review of an [MEDICATION NAME] lab test dated 3/13/17 revealed a result of 1.5 (normal 3.5-5.0). Review of R #64's Wound Evaluation Form revealed that he had a Stage II pressure wound to the left buttock. On 2/24/17, the wound was measured as 1.5 cm (centimeters) long by 0.1 cm wide. On 3/3/17, the wound measurements were recorded as 1.0 cm long by 0.5 cm wide. On 3/10/17, the wound was measured as 0.5 cm long by 0 cm wide. Further review of all three of these wound assessments revealed that the depth was left blank in the Size sections of the form. During interview with the Assistant Director of Nursing (ADON) on 3/30/17 at 1:19 p.m., she stated that the nurse that measured and described the wound should have recorded the depth on the Wound Evaluation Form. During further interview, the ADON verified that this had not been done for R #64's left buttock pressure ulcer, and that the nurse should have recorded a 0 (zero) if the wound had no depth. Review of R #64's impaired skin integrity care plan dated 3/16/17 revealed that he had developed a Stage 2 darkish hue boggy blister to the left heel measuring 2.0 cm by 1.0 cm. Review of a Wound Evaluation Form for this left heel pressure ulcer revealed that the only assessment documented was on 3/16/17. Further review of this form revealed that the left heel had eschar in the wound bed. Review of computerized nurse's notes revealed no documentation of the left heel wound measurements and appearance. Review of physician's orders [REDACTED]. On 3/29/17 at 6:43 a.m., Licensed Practical Nurse (LPN) CC was observed performing R #64's left heel wound care. During this observation, no blister was seen, and the left heel appeared to have eschar in the wound bed surrounded by pink tissue. During interview with LPN DD on 3/30/17 at 10:18 a.m., she stated that the 11:00 p.m. to 7:00 a.m. shift nurse did the dressing changes, wound measurements and staging. During interview with the ADON on 3/30/17 at 1:19 p.m., she stated that there was an RN (Registered Nurse) on the night shift that measured and described wounds weekly. The ADON verified that there was no documentation on the Wound Evaluation Form after 3/16/17 for the left heel wound, and the only measurements she could find in the nurse's notes was on 3/18/17. Review of this note revealed the measurement was for the left buttock wound, not for the heel wound. The ADON further stated that if the heel wound contained eschar, that it would be unstageable, but the treatment would remain the same. During interview with the ADON on 3/30/17 at 3:27 p.m., she stated that she was not able to find a facility policy that specified how often wound assessments and measurements should be done. Review of the facility's Wound Evaluation Form revealed to COMPLETE SECTION BELOW (with date, size, stage, drainage, wound bed, undermining/tunneling, and periwound) WHEN AN ULCER IS FIRST DISCOVERED AND ON A WEEKLY BASIS THEREAFTER. | 2020-09-01 |