cms_GA: 7940
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 7940 | ROSEMONT AT STONE MOUNTAIN | 115565 | 5160 SPRING VIEW AVENUE | STONE MOUNTAIN | GA | 30083 | 2013-09-29 | 314 | G | 1 | 0 | ZXFN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and record review, the facility failed to ensure that one (1) resident (#1), of three (3) sampled residents having pressure sores, on the survey sample of eleven (11) residents, received the necessary care to prevent pressure sore reoccurrence. This failure resulted in harm for Resident #1, who developed two dime-sized Stage 2 pressure sores after the failure to provide timely incontinence care. The findings include: Record review for Resident #1 revealed an Annual Minimum Data Set (MDS) assessment with an Assessment Reference Date of 09/03/2013 which documented, in Section C - Cognitive Patterns, that the resident had a Brief Interview for Mental Status score of 4, indicating severe cognitive impairment. Section I - Active [DIAGNOSES REDACTED]. Section H - Bladder and Bowel documented that the resident was always incontinent of both bowel and bladder, and Section G - Functional Status documented that the resident was totally dependent on staff for toilet use. Section M - Skin Conditions of this MDS documented that at the time of the assessment, the resident had no unhealed pressure sores, but that the resident did have a history of Stage 2 pressure sores. Further record review for Resident #1 revealed no documented evidence of any current pressure sores. During an observation conducted in the day room on 09/21/2013 at 12:00 noon, Resident #1 was observed to be seated in a geri-chair, and a strong urine odor was noted at that time. During a later observation of Resident #1 conducted in the resident's room on 09/21/2013 at 2:24 p.m., the resident was observed in bed. A strong urine odor was noted upon entering the room, which was even stronger at the resident's bedside. During an interview with Certified Nursing Assistant (CNA) EE conducted on 09/21/2013 at 2:35 p.m., this CNA stated that he had changed Resident #1's brief just before the resident's lunch tray arrived around 1:00 p.m., at the request of a nurse who had indicated that the resident smelled. The CNA stated that when the nurse asked him to change Resident #1, that was when he had changed the resident. During an interview with Charge Nurse FF conducted on 09/21/2013 at 2:40 p.m., Charge Nurse FF stated that Resident #1 had eaten breakfast in the dining room that morning at around 7:30 a.m., and that the resident had then been taken back directly to the day room after breakfast, then had remained there for the entire morning. Charge Nurse FF acknowledged that she had asked CNA EE to change Resident #1 at 1:00 p.m., when she had smelled an overpowering urine odor in the day room. During an observation of Resident #1 with Nurse FF and Nurse GG conducted on 09/21/13 at 2:42 p.m. in the resident's room, Resident #1's diaper was dry, however, the draw sheets under the resident were observed to be saturated with urine. These nurses said it appeared that CNA EE had changed the resident's brief during the earlier incontinence care, but did not change the wet draw sheets. Additionally, it was noted, and acknowledged by both nurses during the observation, that two open pressure sores were located on Resident #1's buttocks. During a 09/21/2013, 3:10 p.m. observation of Resident #1 with the Wound Manager/Assistant Director of Nursing in attendance, two dime-sized Stage 2 pressure ulcers were observed on the resident's buttocks. During an interview with this nurse conducted at the time of this observation, she stated that these two pressure ulcers were new. She further stated that CNAs were supposed to report new open skin areas to the charge nurse. Based on the above, Resident #1, who was incontinent of both bowel and bladder, had been placed in the day room for the entirety of the morning of 09/21/2013 without receiving incontinence care until approximately 1:00 p.m., by which time the resident was noted by nursing staff to have an overpowering urine smell. Upon observation at 2:42 p.m. on that date, the resident was noted to have two newly-developed dime-sized Stage 2 pressure sores on the buttocks. | 2016-09-01 |