GOLDEN LIVING CENTER – BRANDYWOOD
LOCATED: 555 E BLEDSOE, GALLATIN, TN 37066

PLEASE NOTE: The following highlighted quoted text is only a portion of the full report/survey as published by TENNESSEE DEPARTMENT OF HEALTH. The full report/survey can be found here: https://apps.health.tn.gov/HCF/Inspections/TN8301_C3CC11_09172015_FR.pdf

PLEASE NOTE: On 10/21/15 Federal Recertification Follow Up shows the deficiency has been corrected on 10/16/2015.  The full report can be found here: https://apps.health.tn.gov/HCF/Inspections/TN8301_C3CC22_10222015_FLRF.pdf

Based on policy/procedure review, clinical record review, observation, and interview, the facility failed to accurately assess, monitor, and provide care and services to ensure that a resident without a pressure ulcer did not develop them.

Failure to provide appropriate care and services to prevent 2 residents (Resident #85 and 1) from developing a pressure ulcer and 1 (Resident #85) developed a pressure ulcer and ultimate infection, of 4 residents reviewed for pressure ulcers, which resulted in actual harm for Resident #85. The facility identified a census of 76 residents, sample size included 31 residents.

Review of the medical record for Resident #85 revealed he was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The resident had no pressure ulcers on admission. Resident #85 was not interviewable. A confidential interview on 9/14/15 at 11:52 AM, revealed Resident #85 had developed a pressure ulcer on the right hip or buttocks and now it was infected and the resident had been placed in isolation. The interview further revealed that the resident was not being showered or turned often enough to promote healing.

Interview with Nursing Staff #24 on 9/14/15 at 3:00 PM, revealed Resident #85 had an unstageable pressure ulcer to the right hip. The wound was now infected and the resident was in isolation.

A wound care observation was conducted with Nursing Staff #22 on 9/15/15 at 3:50 PM, for Resident #85. While providing wound care, the nurse removed the old dressing and packing from Resident #85’s pressure ulcer. The nurse then proceeded to remove her soiled gloves and don new gloves without washing her hands. Measurements of the wound were taken including the tunneling and the nurse proceeded to remove her soiled gloves and don new gloves without washing her hands. Lack of hand washing during wound care could contribute to infection and cross contamination.

Observations of Resident #85 on 9/16/15 at 9:00 AM, revealed the resident to be lying on his/her left side in bed. He was wearing the same blue shirt from 9/15/15. He/she did not respond to questions.

Observations of Resident #85 on 9/16/15 at 10:00 AM, revealed the resident continued to lie on the left side.

Observations of Resident #85 on 9/16/15 at 11:30 AM, revealed the resident to be in the same position. There was no evidence of turning or positioning by staff.

Interview with Administrative Staff #4 on 9/17/15 at 2:18 PM, revealed the facility had problems with identifying and assessing wounds when he/she started working in the building. Administrative Staff #4 could not confirm what Administrative Staff #12 looked at when completing the required assessments.

Failure of the facility to properly assess Resident #85’s skin condition, develop and implement an appropriate plan of care following the facility policy, that included a turning and positioning schedule, resulted in Resident #85 developing a pressure ulcer and ultimate infection, which resulted in actual harm for this resident.

THE ADVERTISEMENT IS NEITHER AUTHORIZED NOR ENDORSED BY THE DEPARTMENT OF HEALTH, DEPARTMENT OF MENTAL HEALTH AND SUBSTANCE ABUSE SERVICES, OR ANY OTHER GOVERNMENTAL AGENCY

Personal Note from NHA-Advocates: NHAA shares 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 else. We expect our loved ones to be 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.

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