cms_GA: 8404
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 |
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8404 | BROWN HEALTH AND REHABILITATION | 115090 | 545 COOK STREET | ROYSTON | GA | 30662 | 2011-10-06 | 309 | G | 0 | 1 | Z6CD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview the facility failed to assess and treat pain experienced during pressure sore treatments for two residents, #112 and #23 of thirty-three (33) sampled residents. This resulted in actual harm to residents #112 and #23. Findings include: 1. Review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed resident # 112 was assessed at risk for pressure sores and was assessed as having a Stage II pressure sore which was present on admission. Review of the current Comprehensive Care Plan revealed the resident had a current Stage II pressure sore on the left lateral foot. The Treatment Nurse and Certified Nursing Assistants (CNAs) JJ and KK were observed on 10/05/11 at 10:15 a.m. while doing a pressure sore treatment to the resident's left lateral foot. The resident called out in pain each time the wound was touched. The resident also verbally expressed pain when the old dressing was removed. The Treatment Nurse acknowledged the resident's expressions of pain and stated she would check with the Medication Nurse after the treatment to find out when he was last medicated. CNAs JJ and KK proceeded with the treatment. The resident asked the Treatment Nurse to check with the Medication Nurse. The Treatment Nurse left the room and returned stating he had his last pain medication at 2:o'clock. The treatment was completed. Review of the resident's current Physician order [REDACTED]. Review of the MAR for October 2011 revealed the resident received this medication for the first time in October 2011 on 10/05/2011 following completion of the pressure sore treatment. Review of the current Comprehensive Care Plan revealed the resident was care planned to receive support related to pain. Interventions included medicate for pain as needed and monitor effectiveness. 2. Review of the quarterly Minimum Data Set (MDS) Assessments dated 4/27/11 and 7/27/11 revealed resident # 23 had a healing Stage IV on the right heel. Review of the current Comprehensive Care Plan also revealed the resident had a Stage IV, now presenting as a Stage II on the right heel. Interventions included monitoring for pain and medicating as needed. The Treatment Nurse and Certified Nursing Assistants (CNAs), JJ and KK were observed doing the treatment to the pressure sore on 10/05/11 at 10:40 a.m. The resident winced when her foot was raised to begin the treatment. The resident winced and verbalized pain when the area was cleansed. CNA JJ asked her if it hurt and the resident said it hurt when touched. CNA JJ proceeded with the treatment. When the treatment was complete the Treatment Nurse asked the resident if she wanted a pain pill. The resident said it stopped hurting once the treatment was completed. Review of the current Medication Administration Record [REDACTED] Review of the facility's policy on Pain Management revealed residents should be assessed and kept free of pain as much as possible. The facility's Pressure Sore Treatment Policy did not address pain The Treatment Nurse was interviewed on 10/06/11 at 11:20 a.m. and stated she did not feel resident #23 had pain during treatments, but acknowledged the resident did indicate pain when the area was touched. She further stated resident #112 did express pain during his treatment and that the treatment should have been stopped until the resident had pain medication with relief. During an interview on 10/06/11 at 12:25 p.m. the Director of Nursing (DON) stated she would have expected the nurse to stop the treatment, cover the wound with a dry sterile dressing (DSD), medicate the resident for the pain and wait an hour before resuming the treatment. | 2016-01-01 |