cms_GA: 177
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 177 | SIGNATURE HEALTHCARE OF BUCKHEAD | 115110 | 54 PEACHTREE PARK DRIVE N.E. | ATLANTA | GA | 30309 | 2018-04-17 | 565 | D | 1 | 0 | TFUK11 | > Based on observation, record review and staff and family interview, the facility failed to resolve grievances filed for one resident (R), (R#4) from a sample of six residents. The facility census was one hundred thirty-two. Cross refer to F 355 Findings include: A family interview for R#A on 4/11/18 at 2:01 p.m. revealed she has discussed with the facility the family's wishes for R#A to wear proper clothing at all times. The family member revealed she had found R#A with out pants on when in bed, clothed only in a brief and shirt, or brief and pajama top at night, more than once. The family member revealed she has explained to the facility that the resident should wear pants when in bed during the day for naps and wear pajama bottoms at night when in bed. She revealed she brings home the resident's laundry and knows she has not been properly dressed when she finds 2 pajama tops and one or no pajama bottoms. She was unable to give dates and times when she has found the resident in bed with no pants on but it has happened more than once and she has found this recently. The family member confirmed she had expressed the family's wishes to the Administrator by email, at care plan meetings, in grievances and individually to Certified Nursing Assistants and Nurses over the last year, with improvement sometimes for a brief period, possibly a week then she will find her aunt without pants or pajama bottoms on in bed again. She revealed she has also repeatedly asked for lotion or oil to be applied to her aunt's skin every day and when laundering the clothing she is aware that this is not being done because the clothing sometimes has an excessive amount of dry skin on the inside. She revealed she intermittently also finds the residents pants and pajama bottoms soaked with an excessive amount of urine, like she had not received incontinence care at regular intervals and has included this in discussions, emails, and grievances without results. Record review of Care Plan Conference Summary, dated 6/20/17 revealed the family member of R#A expressed concerns regarding proper dress attire at bedtime, and regarding bedtime hygiene, dress and incontinence care. Review of a second Care Plan Conference Summary indicated on 12/14/17 the family member of R#A discussed proper dress at bedtime during a conference call. Review of Entity Reported Incident GA 476, reported on 1/23/18 revealed the Administrator received an email from the family member of R#A indicating the family had asked over and over to shower R#A and oil her skin, and that this matter had been addressed many times during care plan conversations, but they were still having this issue. The writer of the email indicated if the showers and oiling her skin had been consistent she would not find excessive amounts of dry skin in her clothes regularly. The facility Administrator replied the wound care nurse would assess R#A's skin and the facility would also look at her hydration and educate staff on skin care including the usage of lotion. Continued review of Entity Reports revealed on 3/30/18 the Administrator received an email from the family member of R#A indicating that there was dry skin on her aunt's clothes and her pants were wet, and she believed this was a form of abuse. The facility investigated by having the charge nurse conduct a skin assessment, and assess for dehydration. The CNA's were in-serviced regarding the frequency of incontinence care and change of clothing as needed. On 4/10/18 an email was received from the family member of R#A, which had been sent to the Administrator and the Director of Nurses regarding continuing to find wet pants in the laundry, and indicating if she were to find R#A without pants there would be a major problem. Review of CNA Care Report, no date, revealed R#A is to have ointment to skin every bedtime (HS) and with ADL care, the resident is non ambulatory, requires one assist for transfers and on the reverse side was an intervention to use pajama tops and bottoms and if they are wet change both items. During an interview conducted on 4/11/18 at 4:45 p.m. LPN EE revealed R#A had been put to bed by CNA's at 2:00 p.m. An observation on 4/11/18 at 4:55 p.m. revealed R#A was in bed with a T shirt, a pink over shirt and an incontinence brief on. The resident's wheel chair was parked in front of the sink. The pink pants matching the shirt R#A had been observed wearing when she was up in the common areas that day were folded in half twice and were on the seat of the chair out of reach beyond the foot of the bed. An interview was conducted with CNA FF on 4/11/18 at 4:56 p.m. in the room of R#[NAME] CNA FF revealed R#A had been put to bed by the day shift CNA's and was not mobile enough to get up, take off her pants, fold them and put them on the chair and return to the bed unassisted. CNA FF revealed she knew not to put the resident to bed without pants because the CNA Care Plan indicated she should have pants on and she had been told by the family to keep pants or pajama bottoms on R#[NAME] CNA FF revealed R#A must have been put to bed without her pants on. Review of CNA Activity of Daily Living (ADL) sheets revealed on 4/11/18 at 1:52 p.m. R#A had been toileted, and transferred and required one persons physical assist for bed mobility. Review of facility Policy titled Investigate Complaint/Grievance, no date, revealed the Social Service Director or designee will coordinate efforts to comply with this policy. The flowing procedures provide a prompt, thorough and equitable resolution of Resident voncerns and/or complaints. | 2020-09-01 |