PRUITTHEALTH – AUGUSTA HILLS NURSING HOME
Located 2122 CUMMING ROAD AUGUSTA, GA 30904 was cited by the DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES (DHHSCMMS) recently as of September 2013 for failure to monitor a catheter of their elderly resident; which caused severe pain, sepsis and resulted in ICU hospitalization. DHHSCMMS discovered through the NH and hospital notes the catheter was occluded by mold, causing harm to the resident (acute urinary tract infection & acute kidney injury) and had been unchanged for over two weeks.
The following are only direct quote portions of the report. The full report can be found here.
WARNING: The following can be disturbing to some readers.
The facility neglected Resident #1 by failing to provide ongoing indwelling urinary catheter observation and monitoring, per facility protocol. This failure of facility staff to observe and monitor, per protocol, resulted in the delay of staff identifying that the indwelling urinary catheter of Resident #1 had become occluded with mold. The resident was subsequently transferred to the hospital and admitted to the Intensive Care Unit in critical condition with a urinary tract infection, [MEDICAL CONDITION], acute kidney injury related [MEDICAL CONDITION]/urinary tract infection, and severe metabolic acidosis. This resulted in a situation in which the facility’s non-compliance with the requirements of participation caused, or had the likelihood to cause, serious harm, injury or death to residents.
The facility’s failure to ensure urinary catheter monitoring per facility protocol resulted in a delay in staff identifying that Resident #1 had sustained an occluded urinary catheter, allowing the resident to become septic, and resulting in the resident being transferred and admitted to the hospital in critical condition.
However, further record review revealed no evidence to indicate that facility staff observed or monitored Resident #1’s indwelling urinary catheter at all after this 08/09/2013, 9:00 a.m. Nurse’s Notes entry until 08/25/2013 (fifteen sequential days). An untimed Nurse’s Notes entry of 08/25/2013 documented that Resident #1 was complaining of abdominal pain, that the resident was crying out with increased pain, that the resident’s urine output had been less than 100 milliliters, and that the resident had been transferred to the hospital. Resident #1’s hospital ED Provider Notes (EDPN) of 08/25/2013 p.m. documented that, upon arrival at the emergency room , Resident #1’s urinary catheter was occluded by mold, and that the resident was moaning and had lower abdominal distension. The EDPN also documented that when replaced, the urinary catheter drained cloudy urine, and that Resident #1 stopped moaning. The EDPN also documented that Resident #1 was referred to Critical Care and admitted to the Intensive Care Unit (ICU) in critical condition. Resident #1’s Critical Care Admission Note (CCAN) of 08/25/2013 revealed that the resident was admitted to ICU having [MEDICAL CONDITION], a urinary tract infection present on hospital admission, acute kidney injury related to [MEDICAL CONDITION]/urinary tract infection, and severe metabolic acidosis. This CCAN also documented the administration of intravenous antibiotic [MEDICATION NAME]-tazobactam. During the interview with the Administrator and DON conducted on 09/11/2013 at 12:20 p.m., these staff members acknowledged that there was no evidence to indicate indwelling urinary catheter monitoring had been done twice daily, per facility procedure. Based on the above, the facility neglected Resident #1 by failing to observe and monitor the status of the resident’s indwelling urinary catheter twice daily, per facility protocol, after the 07/25/2013 insertion of the indwelling urinary catheter.
Additionally, facility nursing staff failed to monitor the resident for signs and symptoms of infection from 08/09/2013 until 08/25/2013 (sixteen sequential days), even though the 07/24/2013, 1:00 p.m. Nurse’s Notes entry referenced above noted the need for monitoring for signs of infection, and even though the facility’s Changing of Catheters Policy referenced above indicated that a reason for catheter change would be signs and symptoms of infection. On 08/25/2013, after fifteen sequential days with no evidence of monitoring, Resident #1 complained of abdominal pain and had decreased urine output.
Personal Note from NHAA Advocates: We here at NHAA share with all the families of loved ones who are confined to nursing homes the pain and anguish of putting them in the care of someone other than our-self. We live our lives thinking our loved ones are being treated with dignity and honor in the homes we place them. We cannot emphasize enough to family members of nursing home residents; frequent visits are essential to our loved ones’ well being and safety. This nursing home and many others across the country are cited for abuse and neglect which go unpunished and continue to turn a blind eye to our elders’ safety and well being.
You can make a difference. If you have a loved one living in this nursing home or any other nuring home where you suspect any form of abuse or neglect, contact us immediately. We can help you file a state complaint, hire a specialized nursing home abuse and/or neglect attorney or help you find a more suitable location for your loved one.
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