Pruitthealth - Fort Oglethorpe

In the surveyor’s words

From the most serious findings on record at Pruitthealth - Fort Oglethorpe, in the surveyor’s own words.

• Actual harm, isolatedF656Jan 12, 2023

  Based on observations, interviews, record review, and facility policy review, it was determined the facility failed to ensure the comprehensive care plan addressed the need for pain management prior to and/or during wound care for one of three sampled residents (R) (R#94) reviewed for pain management. The resident was observed to exhibit signs and symptoms of pain throughout a wound care procedure on 1/11/23 but did not receive pain medication until the surveyor intervened. Findings included: A review of a facility policy titled, Care Plans, effective dated 12/31/96, revealed. […]

• Actual harm, isolatedF697Jan 12, 2023

  Based on observation, interviews, record reviews, and facility policy review, it was determined the facility failed to ensure pain medication ordered on an as-needed (PRN) basis was administered prior to and/or during wound care for one of three sampled residents (R) (R#94) reviewed for pain during wound care. Specifically, no pain medication was administered to R#94 prior to wound care, and when the resident exhibited signs and symptoms of pain, the licensed nurse continued the wound care without administering pain medication until the surveyor intervened. This failed practice resulted in R#94 repeatedly exhibiting signs and symptoms of pain while wound care was provided. […]

• No harm, potential for more than minimal, widespreadF812Sep 12, 2024

  Based on observations, staff interviews, and review of the facility's policies titled, Receiving and Storage of Food and Supplies and Hand Washing, the facility failed to ensure food stored in the kitchen was labeled, dated, and not expired. Additionally, staff failed to perform adequate hand hygiene when leaving and returning to food preparation area after touching the lid of trash can. This had the potential to increase the spread of foodborne illness and infection for 108 out of 109 residents that received meals from the kitchen. Findings include: Review of facility policy titled, Receiving and Storage of Food and Supplies dated [DATE]. Under the section labeled Guidelines: 1. The DM or trained designee is accountable for receiving and storage of food .7. […]

• No harm, potential for more than minimal, widespreadF812Apr 15, 2021

  Based on observations, staff interviews, review of the facility policy titled Food Temperatures and record review revealed the facility staff failed to maintain several hot food items on the serving line at 135 degrees Fahrenheit (F) or above and one cold food item at 41 degrees Fahrenheit (F) or below, which had the potential to affect 82 of 82 residents receiving an oral diet. Findings include: Review of the policy titled Food Temperatures revised 3/24/2016 revealed: Procedure: 1. All hot foods served from the steam table must be held at or above 135 degrees. 2. All potentially hazardous cold foods must be held at 41 degress or less. 3. Food temperatures will be taken before and after serving, temperatures will be logged directly on the Food Temperature Log form. […]

• No harm, potential for more than minimal, patternF623Sep 12, 2024

  Based on resident and staff interviews and record review, the facility failed to provide a written notice of a transfer to the resident and/or resident's Responsible Party (RP) for three of three residents (Resident (R) 80, R32, and R73) reviewed for hospitalization out of a sample of 32 residents. This had the potential for the resident and or RP not knowing where and why a resident was transferred. Findings include: 1. Review of the Resident Face Sheet located in the electronic medical record (EMR) under the Face Sheet tab documented R80 was admitted to the facility on [DATE] and had a diagnosis of dementia. […]