cms_GA: 8682
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 |
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
8682 | SIGNATURE HEALTHCARE OF SAVANNAH | 115120 | 815 EAST 63 STREET | SAVANNAH | GA | 31405 | 2012-03-29 | 314 | 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 report that a pressure ulcer dressing was soiled; failed to change a pressure ulcer dressing per physician's orders [REDACTED].#164). The sample size was thirty-six (36) residents. Findings include: Review of resident #164's Significant Change Minimum Data Set ((MDS) dated [DATE] noted that they were totally dependent on staff for activities of daily living. It assessed the resident as having experienced a non-prescribed weight loss, and currently had pressure ulcers. [DIAGNOSES REDACTED]. A Resident Weekly Skin Check Sheet dated 02/24/12 noted new reddened areas below the right fifth toe, right hip, and left ankle. A Patient Nursing Evaluation dated 03/05/12 noted the Braden Scale assessed the resident as high risk for pressure ulcer development, with risk factors of needing staff assist to move; bed or chair bound; dementia; and malnutrition. A [MEDICATION NAME] lab (used to detect protein-calorie malnutrition) done on 03/05/12 was 9 (normal 16-39). physician's orders [REDACTED]. The Treatment Record scheduled these to be done once on the 7:00 a.m. to 3:00 p.m. (7-3) shift, and once on the 3:00 p.m. to 11:00 p.m. (3-11) shift. On 03/28/12 at 10:03 a.m., the Treatment Licensed Practical Nurse (LPN) was observed performing wound care for resident #164, and was assisted by Certified Nursing Assistant (CNA) AA. The dressing to the sacral area was dated 3/27. The bottom third and up the left side of the dressing was soiled with stool. When the sacral dressing was removed, the resident was noted to have a large Stage IV pressure ulcer. On 03/28/12 at 10:56 a.m., CNA AA stated she came to work at 7:00 a.m. that morning, and that the sacral dressing was soiled with stool at that time. At 11:00 a.m., the Treatment LPN stated the medication nurses did skin assessments on all residents weekly. She stated that she was not aware of any reddened areas noted on the 02/24/12 Skin Assessment until 02/27/12, when a CNA told her. In addition, she said that the sacral dressing that she changed that morning was the same dressing she applied yesterday morning. She stated 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 3-11shift on 03/27/12 was ever done. On 03/28/12 at 3:15 p.m., the Director of Nurses (DON) stated they just completed an inservice with staff including reporting when they noted a soiled dressing, and to do treatments as ordered. On 03/29/12 at 10:15 a.m., the DON provided a facility policy on Preventative Skin Care, which noted to report to the charge licensed nurse any signs and symptoms of skin issues, including redness. | 2015-11-01 |