Harborview Tifton
HARBORVIEW TIFTON in TIFTON, GA — inspection on March 12, 2025.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Findings included:
A review of the undated policy titled Administering Pain Management, it was documented that the pain management program was based on a facility-wide commitment to appropriate assessment and treatment of pain, based on professional standards of practice, the comprehensive care plan, and the resident's choices related to pain management. It was noted that Pain Management was defined as the process of alleviating the resident's pain based on his/her clinical condition and established treatment goals and that Pain Management was a multidisciplinary care process that included the following: assessing the potential for pain; recognizing the presence of pain; identifying the characteristics of pain; and addressing the underlying causes of the pain.
1. A review of the electronic medical record (EMR) revealed that R1 was admitted to the facility with diagnoses of type 2 diabetes mellitus, chronic gout, metabolic encephalopathy, pressure ulcer, hypertensive heart disease, dementia, pain, and glaucoma.
During an observation on 3/5/2025 at 10:39 am, R1 was lying in bed on an airflow mattress with bilateral assistive rails in the upper position and had a wedge and a pillow for positioning.
Wound Nurse/Licensed Practical Nurse (LPN) CC was being assisted by LPN DD and Certified Nurse Certified (CNA) SS to provide the resident with wound care treatment. LPN CC washed her hands, and CNA SS removed the resident brief and provided perineal care.
The wound bed was 80% yellowish slough and 20% reddish granulation. LPN CC cleaned the wound with wound cleanser, and while cleaning the wound, R1 was observed voicing, Ouch, ouch, ouch.
That hurts. LPN CC continued to obtain wound measurements of 8.5L x 3.1W x 4.7D. LPN CC began checking for undermining using her finger and again the resident began saying, Oh, oh and tried moving away from LPN CC's hand. LPN DD told R1 to take a deep breath and that it was almost over. LPN CC continued applying the Dakin solution on a kerlix and packing the Dakin-moistened kerlix into the wound bed. LPN CC then placed an adhesive border dressing over the moistened kerlix. R1 continued squirming on the bed throughout the dressing change (moving away from the nurse's hands).
Further observation revealed a sign on R1's door documenting that enhanced barrier precautions were in place. LPN CC, LPN DD, and CNA SS were not wearing a gown as they performed wound care and/or perineal care.
A review of the Order Summary Report dated 3/5/2025 revealed R1 had an order for Tylenol 325 milligrams (mg) tablet, to administer two tablets orally every six hours as needed for pain related to pressure ulcer of the sacral region with an order and start date of 3/4/2025.
A review of the Medication Administration Record (MAR) dated 3/1/2025 through 3/31/2025 revealed no evidence that Tylenol was administered.
115412
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 115412 B.
Wing 03/12/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Harborview Tifton 1451 Newton Drive Tifton, GA 31794