cms_GA: 8678
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 |
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
8678 | SIGNATURE HEALTHCARE OF SAVANNAH | 115120 | 815 EAST 63 STREET | SAVANNAH | GA | 31405 | 2012-03-29 | 282 | D | 0 | 1 | G6KB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to consistently follow the care plan related to treatments, reporting skin concerns, and skin checks for one (1) resident (# 164) with pressure sores. The sample size was thirty-six (36) residents. Findings include: Review of resident #164's medical record revealed that they had multiple pressure ulcers. A Nursing Home Orders hospital discharge form dated 03/05/12 noted to change the dressing to the resident's sacrum twice a day, and this was scheduled on the Treatment Record to be done on the 7:00 a.m. to 3:00 p.m. (7-3) shift and the 3:00 p.m. to 11:00 p.m. (3-11) shift. Review of the Impaired Skin Integrity care plan included approaches to perform treatments per physician's orders [REDACTED]. Review of the Resident Weekly Skin Check Sheets revealed that after admission to the facility on [DATE], a skin assessment was not performed until 12/12/11. Per the 02/24/12 skin assessment, the nurse noted reddened areas below the right fifth toe, right hip, and left ankle. On 03/28/12 at 10:03 a.m., Treatment Licensed Practical Nurse (LPN) was observed performing wound care for resident #164. The dressing to the sacral area was dated 3/27. At 11:00 a.m., the Treatment LPN stated that the sacral dressing that she just changed was the same dressing she applied yesterday morning. She added the order was to change the dressing twice a day, and there was no documentation on the Treatment Record that the dressing scheduled to be changed on the 3-11 shift was ever done. She stated that the nurses did skin assessments on all residents weekly, and verified there were no skin assessments done on 11/28/11 and 12/05/11. She added that she did not start treatments to the reddened areas of skin noted on the 02/24/12 skin assessment until 02/27/12, because she was not notified until then. On 03/28/12 at 3:15 p.m., the Director of Nurses (DON) stated that the evening nurse was responsible for doing the 3-11 dressing change. On 03/29/12 at 8:40 a.m., she stated the facility protocol was to do weekly skin assessments. Cross-refer to F 314. | 2015-11-01 |