cms_GA: 7704
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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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 7704 | AUTUMN BREEZE HEALTH AND REHAB | 115580 | 1480 SANDTOWN ROAD SW | MARIETTA | GA | 30008 | 2014-01-08 | 281 | D | 1 | 0 | TEVL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, state board of nursing nurse practice act review and laboratory report review the facility failed to ensure that the nursing services provided met professional nursing standards of quality for two (2) residents (#1, #2) that were at risk for the development of pressure ulcers and one resident (#1) with abnormal laboratory results of five (5) sampled residents. The nursing staff failed to fully inform the physician of the status of laboratory results for Resident #1 which delayed the treatment for [REDACTED].#1 and failed to inform the physician of the development of a pressure ulcer for Resident #2. Findings include: The Georgia Registered Nurse Practice Act, Article 43-26-3(6) indicates that the Practice of Nursing includes the provision of nursing care: administration, supervision, evaluation, or any combination thereof, of nursing practice. 1. 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, and said to wait for culture. The nurse documented on the Lab Report that there was 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. 2. Review of the Admission Record for Resident #1 indicated the resident was admitted into the facility on [DATE]. 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 (9 days after admission) indicated that Resident #1 ' s pressure ulcer to the coccyx measured 7.0 x 9.5 x 0.2 cm and was un-stageable. The wound had deteriorated and had 100 % necrotic tissue. There was no documentation on the health record that the primary physician and wound specialist were notified of the deterioration of the pressure ulcer on Resident #1's coccyx. Interview with the wound care nurse on 01/02/13 at 9:30 AM revealed that the nurse recalled Resident #1. According to the wound nurse there was no depth to the coccyx wound and there was 50% pink healthy tissue, 10% granulation tissue and the wound had scattered with yellow slough on admission. 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. 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]. Interview with the assistant director of nursing (ADON) and the wound nurse on 1/2/14 at 10:40 AM revealed that the facility was 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 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. Review of the Care Plan for Pressure Ulcers dated 12/06/13 for Resident #1 indicated that one of the interventions for the pressure ulcers was to notify the MD as needed (prn) with any changes in skin integrity. 3. Clinical record review of the Admission Record for Resident #2 revealed that the resident was admitted into the facility in October of 2013. There was no reference to a pressure ulcer on the Admission Record. 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. 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). 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. 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. | 2017-01-01 |