cms_GA: 1606
Data source: Big Local News · About: big-local-datasette
rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
1606 | PINE KNOLL NURSING & REHAB CTR | 115443 | 156 PINE KNOLL DRIVE | CARROLLTON | GA | 30117 | 2019-08-30 | 609 | D | 1 | 0 | QEF711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, review of a policy titled Abuse, Neglect and Exploitation the facility failed to notify the State Survey Agency (SSA) within the required two-hour time period after Resident (R) #1 sustained an injury of unknown source, a hematoma (bruise) on his forehead. This failure affected one resident (R#1) of three sampled residents. Findings include: Review of the undated face sheet in the Electronic Health Record (EHR) revealed R#1 was admitted to the facility in the spring of 2019 and his [DIAGNOSES REDACTED]. Review of the 7/29/19 Quarterly Minimum Data Set, section C, revealed R#1's Brief Interview for Mental Status (BIMS) score to be three out of 15, signifying severe cognitive impairment. Review of section G revealed R#1 required extensive assistance for nearly all Activities of Daily Living (ADLs). Review of a 7/21/19 at 7:35 p.m. progress note revealed a large hematoma was noted on R#1's forehead, the previous shift denied knowledge of the injury, R#1 could not provide history of the hematoma, and the injury was unwitnessed. Review of the policy titled Abuse, Neglect and Exploitation, updated on 12/2017, revealed revealed Injuries of Unknown Source to be defined as the source of the injury was not observed by any person or the source of the injury could not be explained by the resident. Further review revealed the definition to also include the injury was suspicious because of the extent of the injury or the location of the injury. Further review revealed an immediate investigation should take place when abuse is suspected, such as an injury of unknown origin. An interview with the Administrator on 8/29/19 at 2:40 p.m. revealed that she first became aware of R#1's injury of unknown origin to his forehead on 7/22/19, the day after it was first documented by the duty nurse. The Administrator stated all injuries of unknown origin must be reported to the SSA within two hours of discovery, with no exceptions. The Administrator stated the nurse did not report this injury to her when it occurred. The Administrator further revealed that she was the Abuse Coordinator for the facility. An interview with the Regional Nurse Consultant (RNC) on 8/29/19 at 3:00 p.m. revealed that he agreed that R#1's injury of unknown origin occurred on 7/21/19 at about 7:35 p.m. and was not reported to the SSA until the following day, outside the required two-hour time window for reporting injuries of unknown source to the SS[NAME] | 2020-09-01 |