cms_GA: 7866
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 7866 | GOLDEN LIVINGCENTER - WINDERMERE | 115291 | 3618 J DEWEY GRAY CIRCLE | AUGUSTA | GA | 30909 | 2012-01-26 | 328 | D | 0 | 1 | BSSQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview the facility failed to provide care and services related to respiratory care for two (2) residents, resident # 238 and resident C and to ensure diabetic foot care for one resident, resident #113 on a sample of forty-two (42) residents. Findings include: 1. On 1/25/12 at 7:30 a.m. resident # 238 was observed in bed with an empty unsecured oxygen cylinder next to his bed. The nasal cannula was laying on the top of the cylinder exposed to the air. There was no signage on the door indicating oxygen was in use. Review of the nurses notes dated 1/24/12 at 11:40 p.m. revealed that resident #238 had respiratory wheezing and his oxygen (O2) saturation was low at 87% on room air. The physician was notified and orders received for oxygen 2 liters a minute by nasal cannula, [MEDICATION NAME] sulfate jet nebulizer treatments every six (6) hours as needed to address the wheezing and low oxygen saturation. Observation of the resident on 1/25/12 at 8:15 a.m. revealed that Physical Therapy (PT) Technician was performing PROM and the unsecured oxygen cylinder remained next to the bed with the nasal cannula on the top of the cylinder and the resident was not receiving oxygen therapy. Observation at this time, with the West Wing Register Nurse (RN) Unit Manager, revealed the oxygen cylinder should be secured in a holder and the nasal cannula was not stored properly. She stated she was not aware the resident had been put on oxygen. Observation of resident # 238 on 1/25/12 at 10:20 a.m. revealed that he was receiving oxygen by nasal cannula thru an oxygen concentrator at 4.5 liters per minute. This was verified by Licensed Practical Nurse (LPN) LL, who after checking the orders, reduced the flow rate to 2 liters. 2. Interview with resident C on 1/26/12 at 9:50 a.m. revealed that they were on a respiratory machine for sleep apnea. The resident told the surveyor that this was their machine from home and they had used it every night for ten years. The mask and tubing for this machine was observed on the floor under the bed. Review of the initial assessment dated [DATE] revealed that the resident was not assessed as being on a respiratory machine for sleep apnea. Review of the interim care plan revealed that it did not address any respiratory concerns or use of the machine at night when the resident sleeps. Review of the physician orders [REDACTED]. Observation on 10/26/11 at 10:25 a.m. revealed the mask and tubing was off the floor and coiled on the bedside cabinet but not in a storage bag. The machine was not labeled with the resident's name. Review of the nurse's notes from 1/20/12 to 1/25/12 revealed no documentation of the resident needing or using a respiratory machine for sleep apnea at night. Review of the current Medication Administration Record [REDACTED]. Interview with LPN (LL) on 1/26/12 at 10:45 a.m. revealed that she knew the resident had a respiratory machine for sleep apnea in his room. Interview with the R.N. West Wing Unit Manager on 1/26/12 at 10:55 a.m. revealed that she was not aware that resident # C was on a respiratory machine for sleep apnea until just informed by LPN LL. She stated that the family brought in the machine and the night staff were assisting the resident with it's use, but no one else knew about it. 3. Review of resident #113's clinical record revealed [DIAGNOSES REDACTED]. A Diabetes care plan included an intervention for a podiatry consult as needed. A Pressure Ulcer care plan had an intervention for diabetic foot monitoring. On 01/24/12 at 2:20 p.m., Licensed Practical Nurse (LPN) SS verified a two (2) centimeter area of black skin on resident #113's right heel, which she previously was not aware of. The left foot was dry and scaly. The toenails were thick and long, especially the second through fifth toes of the left foot, and the third toe of the right foot. LPN SS stated the resident was seen by a podiatrist monthly, who cut the toenails at that time. On 01/25/12 at 12:10 p.m., Registered Nurse (RN) Unit Manager BB stated she thought that diabetic foot monitoring was done quarterly, but could never find a policy or documentation that this was being done. On 01/26/12 at 7:50 a.m., she said she thought the podiatrist did the diabetic foot monitoring when he visited. At 8:55 a.m., she said the podiatrist told her he had no record of having seen the resident since June of 2011. On 01/26/12 at 8:58 a.m., the Director of Nurses (DON) stated that diabetic foot monitoring was done on admission, and then by the podiatrist who determined how often he would see the resident. On 01/26/12 at 9:55 a.m., LPN Treatment Nurse TT stated they were responsible for scheduling podiatry visits, and that diabetic residents were seen on an ongoing basis. She provided a list of residents scheduled for the podiatrist to see when he was last at the facility on 01/18/12, and resident #113 was on this list. She did not know why the podiatrist did not see the resident. At 11:40 a.m., the DON stated the podiatrist did not see the resident on 01/18/12 because there were so many residents to be seen that day. | 2016-10-01 |