cms_GA: 7703
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 7703 | AUTUMN BREEZE HEALTH AND REHAB | 115580 | 1480 SANDTOWN ROAD SW | MARIETTA | GA | 30008 | 2014-01-08 | 157 | D | 1 | 0 | TEVL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to notify the physician of changes in the health condition of two (2) residents (#1, #2) of five (5) sampled residents. Findings include: 1. Resident #1, the nurse failed to notify the physician of a discrepancy between his response to an abnormal urinanalysis laboratory value report and the actual laboratory tests that were ordered. Review of the Urinanalysis Lab Report for Resident #1 dated 12/12/13 indicated abnormalities that included moderate blood in the urine, moderate leukocytes or white blood cells and cloudy color. There were hand written notes on the Lab Report that documented the physician was notified, wait for culture and no culture ordered. The lab report was initialled by the nurse. Review of the Nurse's Notes for Resident #1 dated 12/12/13 indicated that the urinanalysis results were reported to the physician but the physician stated to wait for the culture results.The nurse failed to notify the physician that there was no urine culture ordered. This failure resulted in a no treatment for [REDACTED].#1. Interview with the assistant director of nursing (ADON) on 12/31/13 at 1:50 PM revealed that the nurse failed to notify the primary physician that a urine culture and sensitivity was not ordered or in progress for Resident #1. When the physician replied to the abnormal report of the urinanalysis that he would wait for the culture and sensitivity results the nurse should have told him that only a urinanalysis was ordered not a culture and sensitivity. On 12/31/2013 at 2:10 PM a telephone interview was made with the assistant director of nursing (ADON) via speaker phone to Resident #1 ' s primary physician regarding the physician's order [REDACTED]. The primary physician said that he was not notified that a culture and sensitivity was not in progress for Resident #1 when the nurse gave him the abnormal urinanalysis results on 12/12/13. He stated that if he had known that there was no culture and sensitivity of the urine in progress he would have treated Resident #1 with antibiotics for the abnormalities identified in the urinanalysis. The primary physician said that the nurse should have informed him that there was no urine culture and sensitivity ordered for Resident #1. Additionally for Resident #1, review of the Admission Record indicated the resident was admitted into the facility on [DATE]. Review of the Cumulative [DIAGNOSES REDACTED].#1 dated 11/27/13 indicated [DIAGNOSES REDACTED]. Review of the Physician order [REDACTED].#1 indicated that the primary physician ordered treatment to the coccyx wound and right gluteal deep tissue injury on 11/27/2013. Review of the admission Non-Decubitus Skin Condition Record dated 11/27/13 indicated that Resident #1 ' s coccyx pressure ulcer measured 7.0 x 9.5 with no depth. The color of the wound bed was pink/yellow. Review of the Wound Care note dated 12/6/13 indicated that Resident #1 ' s pressure ulcer to the coccyx measured 7.0 x 9.5 x 0.2 cm and was un-stageable. According to the treatment nurse's documentation t pressure ulcer on the coccyx had deteriorated and had 100 percent (%) necrotic tissue. Interview with the wound care nurse on 01/02/13 at 9:30 AM revealed that the nurse recalled Resident #1. The wound nurse said that the initial wound assessment was done on 11/27/13 for Resident #1. According to the wound nurse, there was no depth to the coccyx wound and there was 50% pink health tissue, 10% granulation tissue and the wound bed was scattered with yellow slough on 11/27/13. The wound nurse added that there was no visible muscle, cartilage or bone and there was no black tissue and no odor when Resident #1 ' s wound was initially assessed. The wound care nurse said that the wound specialist visited weekly on Tuesday. Resident #1 was admitted on a Wednesday. The next scheduled visit for the wound specialist was on 12/03/13 but that visit was not made. Resident #1 was first seen by the wound specialist on 12/10/13, thirteen (13) days after being admitted into the facility and after the wound had deteriorated. The wound nurse stated that the facility does not contact the wound care specialist to notify them of newly admitted residents. The facility notified the wound care specialist of new residents with wounds only when they were in the facility for weekly rounds. Interview with the assistant director of nursing (ADON) and the wound nurse on 1/2/14 at 10:40 AM revealed that the wound specialist was not notified of new residents with wounds until rounds were made on Tuesdays. No phone notification or written notification was made. The wound care specialist was not notified of the presence of Resident #1 or the deterioration of the pressure ulcers and deep tissue injuries until 12/10/13. Telephone interview with the primary physician on 01/2/14 at 12:00 PM revealed that the primary physician deferred to the wound care specialist for wound care. The primary physician stated that he was unsure whether he was notified of the deterioration of Resident #1 ' s wound but that he left the management of wounds to the wound care team. On 12/10/13 the wound care physician ordered [MEDICATION NAME] Ointment to the coccyx wound bed daily for seven (7) days. According to reference material in Web MD, [MEDICATION NAME] ointment was indicated for treatment of [REDACTED]. The physician continued the daily wound dressings. Review of the facility Skin Program protocol indicated in Step 6 that residents with wounds would have appropriate treatment. If there was deterioration or no change in a wound within two (2) weeks the treatment would be changed. Review of the Care Plan for Pressure Ulcers dated 12/06/13 for Resident #1 indicated that there was a Stage III pressure ulcer on the coccyx and the presence of a deep tissue injury on the right gluteal fold on admission. One of the interventions for the pressure ulcers was to notify the MD as needed (prn) with any changes in skin integrity. 2. Clinical record review of the Admission Record for Resident #2 revealed that the resident was admitted into the facility in October of 2013. Further review of the Admission Record for Resident #2 indicated [DIAGNOSES REDACTED]. There was no reference to a pressure ulcer on the Admission Record. Review of the Treatment Record for Resident #2 indicated that the resident was given pressure ulcer care to a new sacral wound on 10/21/2013. Interview with the wound care nurse on 1/2/14 at 12:56 PM revealed that Resident #2 was admitted into the hospital on [DATE] and readmitted into the facility on [DATE]. The wound nurse said that she was off from work on the weekend of 10/19/13 and 10/20/13 and did not perform the skin check on Resident #2 until Monday 10/21/13. At that time the wound nurse noted the Stage III pressure ulcer to Resident #2 ' s sacrum. The wound nurse said that she thought the wound was hospital acquired because she did not know whether Resident #2 was turned while at the hospital. Further interview with the wound nurse on 1/2/14at 2:00 PM revealed that there was another wound nurse that did a skin assessment on Resident #2 on the weekend of 10/19/13 and 10/20/13, but there was no documentation of the assessment. The wound nurse said that though she documented that she observed Resident #2 ' s pressure ulcer on 10/18/13 she did not actually see and assess the wound until 10/21/13. Further interview with the wound nurse on 1/2/14 at 2:15 PM revealed that she did not actually see the wound on Resident #2 on 10/18/13 but heard by word of mouth of the ulcer. The certified nursing assistant ( AA ) reported the wound to the other wound nurse. Interview with the CNA ( AA ) on 1/2/14 at 2:30 PM revealed that AA worked on 10/19/13. AA said that Resident #2 had a tear/open area on her backside that was red and close to the crack. AA said that when she reported the wound to the other wound nurse on that Saturday the 19 of October the nurse remarked that Resident #2 needed treatment. Interview with the ADON on 1/2/14 at 2:30 PM revealed that she agreed that the wound seemed worst by Monday 10/21/13. The wound should have been treated over the weekend. During the interview with the wound care nurse on 1/2/14 at 2:30 PM the nurse stated that the Stage III ulcer to Resident #2 ' s coccyx measured 3.2 x 2.0 x 0.2 cm on Monday 10/21/13. The wound was reported to the physician on that Monday. Review of the Focused Wound Exam by wound care specialist on 10/22/13 indicated that the Pressure Ulcer on Resident #2 ' s sacrum measured 3.5 cm x 4.5 cm x 0.1 cm depth with necrotic tissue. The physician performed a surgical excisional debridement of the wound. Review of the facility Skin Program protocol indicated in the fourth step that a certified nursing assistant (CNA) will observe resident skin condition daily during care and report skin conditions to the Licensed Nurse. Step 5 indicated that all open areas would be identified and documented on the appropriate forms. Step 6 indicated that residents with wounds would have appropriate treatment. If there was deterioration or no change in a wound within two (2) weeks the treatment would be changed. Review of the Care Plan for Risk for Skin Breakdown dated 10/09/13 for Resident #2 included interventions to report any signs of skin breakdown to the treatment nurse, responsible party and physician (MD). | 2017-01-01 |