cms_GA: 104

In collaboration with The Seattle Times, Big Local News is providing full-text nursing home deficiencies from Centers for Medicare & Medicaid Services (CMS). These files contain the full narrative details of each nursing home deficiency cited regulators. The files include deficiencies from Standard Surveys (routine inspections) and from Complaint Surveys. Complete data begins January 2011 (although some earlier inspections do show up). Individual states are provides as CSV files. A very large (4.5GB) national file is also provided as a zipped archive. New data will be updated on a monthly basis. For additional documentation, please see the README.

This data as json, copyable

rowid facility_name facility_id address city state zip inspection_date deficiency_tag scope_severity complaint standard eventid inspection_text filedate
104 CENTER FOR ADVANCED REHAB AT PARKSIDE, THE 115040 110 PARK CITY ROAD ROSSVILLE GA 30741 2015-10-08 221 E 0 1 6PVM11 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews and interviews, the facility failed to ensure residents were free from the use of side rails to prevent mobility without assessment and/or physician's order reflecting the medical condition requiring use of side rails for six (6) residents (#39, #52, #122, #144, # 101 and #213) from a sample of fifty (50) residents. Findings include: 1. Observations conducted on 10/5/15 at 4:30 p.m. revealed resident #39 in bed with four (4) one-half (1/2) side rails in the up position. Interview conducted on 10/5/15 at 2:31 p.m. with the Licensed Practical Nurse (LPN) QQ responsible for providing direct care for the resident revealed that bilateral full side rails are used every now and then for safety when the resident tried to climb out of bed. Review of medical record reveals Physicians orders dated 2/1/2015 for side rails 1/2 x 2 aid with bed mobility and define parameters of bed. An order on 8/26/2015 Side rails x 2 to aid in bed mobility and define parameters of the bed. The care plan dated 5/24/2014 indicated the resident has a risk of falls and an intervention in place to assure side rails up x 2. 2. Observation conducted on 10/5/2015 at 1:05 PM and 4:20 p.m. revealed resident # 52 in bed with four (4) one-half (1/2) side rails in the up position. Interview conducted on 10/5/2015 at 2:28 PM with QQ revealed four (4) one-half (1/2) side rails are used to prevent falls because the resident climbs out of bed. The resident is capable of getting in and out of bed and the full rails do prevent her from voluntarily getting out of bed. Review of medical record revealed a Physicians order dated 9/28/2015 with NO side rail orders. Review of the residents most recent care plan did not include a plan of care for restraints or use of side rails. The Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview Minimum Status (BIMS) score of two (2). 3. Observations conducted on 10/5/15 at 1:40 PM and 10/6/15 at 2:25 PM revealed resident #122 in bed with four (4) 1/2 side rails in the up position. Interview conducted on 10/5/15 at 2:20 PM with LPN RR responsible for the direct care for resident #122 revealed four (4) 1/2 rails or full side rails are used for safety. RR further revealed the resident wiggles and the rails prevent her from falling out of the bed. Review of medical record revealed a physician ' s order for side rails 1/2 x 2 aid with bed mobility and define parameters dated 10/1/2015. Resident is care planned for use of two (2) side rails up to define parameters. 4. Observation conducted on 10/7/15 at 9:18 AM revealed resident #144 in bed with the bed in the lowered position. Three (3) one-half (1/2) rails were observed in the up position. One (1) on the left side and two (2) on the right side of the bed. Further observation revealed the resident had one (1) leg hanging over the right side of the bed between the two (2) raised rails on that side. Review of the medical record revealed resident #144 was re-admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. The MDS assessment dated [DATE] assessed the resident with a BIMS of ten (10) and required limited assistance of one-person assist with bed mobility, transfers and locomotion and walking. Section P Coded the resident as not having Physical restraints. History of falls 2-6 months Review of the Care Plan dated 9/12/14 revealed no care plan for the use of restraints or side rails. Review of Physician's orders revealed an order for [REDACTED]. 5. Observation conducted on 10/08/2015 at 6:16 AM revealed resident #101 in bed asleep with two (2) full side rails in up position. Interview conducted on 10/8/15 at 7:18 AM with LPN FF revealed resident #101 has two rails at the head of the bed to help him/her get out of the bed. FF further acknowledged she was not aware of the doctor orders for side rails. Review of medical record revealed physicians orders for two (2) side rails to define parameters for this resident dated 10/7/2015. He was care planned for the use of two (2) side rails to define parameters. 6. On 10/7/2015 at 10:00 AM and interview was conducted with the Director of Nurses (DON) during chart reviews of residents with accidents. On 9/28/2015 at 0030 it was documented resident #213 was found in bedrails. Assisted resident in removing legs from rails. Bruising to Right Lower Extremity noted. Physicians and responsible party notified. This resident ' s admission and interim care plan dated 9/24/2015 revealed resident requires side rails. The updated care plan after 9/28/2015 accident requires and intervention of padded side rails x 2. No new physicians orders for side rails on 9/28. There is no evidence of admission orders [REDACTED]. An observation of resident #213 was made with the DON on 10/7/2015 at 1:30 PM. The resident was in bed with four (4) one-half (1/2) rails in the up position and padded with bed length blue pad on the right and left sides of bed secured with Velcro. Review of the facility policy Use of Physical restraints with the Director of Nurses and Administrator on 10/7/2015 at 4:15 PM reveals [NAME] Residents have the right to be free from any restraint imposed for the purposes of discipline or convenience and not required to treat the resident ' s medical symptoms. 1. Physical restraints are defined as any manual method or physical or mechanical device, material or equipment attached to or adjacent to the resident ' s body that the individual cannot remove easily which restricts freedom of movement or normal access to one ' s body. 2. Full side rails used on both sides of the resident ' s bed are considered restraints and are prohibited unless they are necessary to treat a resident ' s medical symptom or used as an enabler or to assist in mobility and transfer of a resident or by the resident ' s request. D. Before a resident is restrained the resident must have a specific medical symptom that would require the use of restraints and how the use of restraints would treat the cause of the symptom and assist the resident in reaching his or her highest level of physical and psychosocial well-being must be demonstrated. F. Prior to using restraints a systematic process of evaluation and care planning will be followed. 1. The presence of a specific medical symptom that would require a restraint. 2. A pre restraining assessment 3. Use of the least restrictive restraint. 4. Education of the restraint/representative. 6. Physicians written order for the use of [REDACTED] 2020-09-01