William Hood Dunwoody Care CTR

In the surveyor’s words

From the most serious findings on record at William Hood Dunwoody Care CTR, in the surveyor’s own words.

• Actual harm, isolatedF686Jun 17, 2021

  Based on a review of the facility policy and clinical record, and staff interview, it was determined that the facility failed to thoroughly assess and provide treatment timely to an identified wound and also failed to notify the physician timely of a change in condition and worsening sacral wound resulting in actual harm of advanced stage pressure ulcer to one of 18 residents reviewed (Resident 162). Findings include: A review of the facility policy titled Skin Integrity, with a revision date of May 11, 2018, revealed that the nurses are responsible for documentation of wound appearance, measurements of wounds, improvements/deterioration, changes in the plan of care, and communication with physicians with recommendations for changes in treatment. […]

• No harm, potential for more than minimal, isolatedF580Apr 4, 2025

  Based on a review of the facility's policy, clinical records review, and staff interview, it was determined that the facility failed to notify the physician of a change in the condition of a resident's urinary status for one of the three residents reviewed (Resident 39). Findings include: A review of the facility's policy titled Change in Resident status Notification, revised on May 17, 2023, revealed that the charge nurse will notify the resident's physician or on-call physician when there has been a significant change in the resident physical/mental/emotional condition, and a need to alter the resident's medical treatment. Notification will be made promptly with the exemption of non-emergency incidents on the 11-7 shift. […]

• No harm, potential for more than minimal, isolatedF686Apr 4, 2025

  Based on clinical records review and staff interview, it was determined that the facility failed to ensure wound treatment for a pressure ulcer was provided for one of five residents reviewed (Resident 39). Findings include: A review of the nursing progress notes dated March 13, 2025, at 7:40 a.m., revealed that a new DTI (Deep Tissue Pressure Injury (DTPI): Persistent non-blanchable deep red, maroon, or purple discoloration) was observed on the resident's left lower back. The wound was cleansed with a wound cleanser and Desitin (An ointment used to treat and prevent a rash) was applied. The Nurse practitioner was notified. A review of the skin assessment dated [DATE], revealed a DTI to the left lower back measuring 8.9 x 4.5 cm (centimeters). […]

• No harm, potential for more than minimal, isolatedF692Apr 4, 2025

  Based on a review of the facility's policy, clinical records review, and staff interview, it was determined that the facility failed to ensure a significant weight change was timely addressed for one 10 residents (Resident 42). Findings include: A review of the facility's policy titled Weights, last revised on October 11, 2024, revealed the facility will have the residents' weights monitored as an indicator of their health and wellness. Residents will be weighed weekly for a total of four weeks to monitor health status. Weights will be reviewed by the nurse and dietitian. Weights that are three pounds greater than or less than the resident's prior weight will be reweighed within 24 hours to verify accuracy. […]

• No harm, potential for more than minimal, isolatedF684May 3, 2024

  Based on review of facility policy and clinical record review, it was determined that the facility failed to ensure one of 18 residents was treated for constipation in a timely manner (Resident 12). Findings include: Review of facility policy, Bowel Protocol, last reviewed/revised June 2, 2022, revealed: If a resident has not moved their bowels for 6 shifts .the 3-11 charge nurse is to give Milk of Magnesia at [bedtime] to the resident with an order. Review of Resident 18's physician's orders revealed an order dated April 4, 2024, for Milk of Magnesia 400mg/5ml - give 30ml by mouth every 24 hours as needed for constipation. Review of Resident 18's bowel records revealed the resident had no recorded bowel movement from April 22, 2024, through April 26, 2024, for a total of 15 shifts. […]