cms_GA: 197
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 197 | SIGNATURE HEALTHCARE AT TOWER ROAD | 115115 | 26 TOWER RD | MARIETTA | GA | 30060 | 2019-01-31 | 689 | G | 0 | 1 | TKWX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review and policy review, the facility failed to ensure each resident received adequate supervision to prevent accidents. Harm was identified when one Resident (R), #4, sustained a [MEDICAL CONDITION] which required sutures after they fell out of the bed during a bath, unsupervised by staff. The sample size was 44 residents. Review of the policy titled, Fall Prevention dated 6/1/15 revealed it was the intent of the facility to provide residents with assistance and supervision to minimize the risk of falls and fall related injuries. Review of the Fall Risk Evaluation dated 8/24/18 revealed the facility had assessed the resident as a 13 which indicated the resident was at risk for falls. Review of the Significant Change in Status Minimum Data Set (MDS) signed and dated 8/7/18 revealed the facility admitted R#4 with [DIAGNOSES REDACTED]. Continued review of the MDS revealed the resident to sometimes make self-understood and usually understands others, moderately impaired vision, short-term and long-term memory problems. The facility assessed the resident not to have displayed behaviors. Continued review of the MDS revealed R#4 required extensive assistance of two staff with bed mobility and personal hygiene, extensive assistance of one staff for dressing, toilet use, and was totally dependent on one staff for bathing. The resident was always incontinent of bowel and bladder. Review of the Care Area Assessment (CAA) Summary revealed the resident had triggered for falls. Review of the Fall-Fall with Injury-Major Investigation dated 9/24/18 at 10:50 a.m. stated, Certified Nursing Assistant (CNA) OO was giving R#4 a bed bath, turned away to the closet to retrieve clothes and towels from the chair when the CNA heard the resident scream, patient noted lying on his right side on the floor beside the resident's bed. Small amount of bright red blood noted draining from the resident's right forehead, hematoma noted. Continued review of the fall investigation revealed the resident was not able to state what had happened and continued to moan out in pain. Review of CNA OO statement dated 9/24/18 stated, As I turned around to retrieve resident's clothes from the closet, I heard him/her scream. R#4 was lying on the floor on his/her right side. Right forehead was bleeding and a hematoma was noted. Review of the Infection Control Nurse LL statement dated and signed 9/24/18 at 11:45 a.m. revealed .Hematoma to right temporal frontal aspect of skull measuring approximately three inches across with serosanguinous drainage .Emergency Medical Services to bedside at 12:00 p.m. Review of the Emergency Department Notes signed and dated 9/24/18 at 1:08 p.m. by a Registered Nurse (RN) revealed the resident arrived from the facility after staff reported he/she was found on the floor at 11:25 a.m. Patient presented with a laceration and a hematoma to the right anterior forehead. Review of the Emergency Department Provider Notes signed and dated 9/24/18 at 2:36 p.m. by a Physician Assistant (PA) revealed R#4 required six sutures to close a three-centimeter laceration on the forehead. Review of R#4's care plan dated 8/7/18 revealed, Problem- resident is at risk for fall as he is dependent on staff for all are related to impaired mobility, [MEDICAL CONDITION], feeding tube and dementia. Goal- Resident will not sustain a fall or fall related injury through next review date. Approach- Staff to provide assistance to meet resident's needs for all activities of daily living. Telephone interview on 1/31/18 at 10:30 a.m. with CNA OO revealed she was with R#4 to provide direct care on 9/24/18. She stated she did not feel she did anything wrong when she turned her back on the resident or left the bed elevated to waist level. She stated she did not see R#4 fall out of the bed, however, when she turned around from the closet and faced the resident, the resident was on the floor. She stated she did have the bed raised to her waist, and it might have been a good idea to put the bed in the lowest position prior to turning her back on him. She stated she did not see an injury to the resident at that time. Interview on 1/30/19 at 12:40 p.m. with CNA JJ revealed anytime care was provided to a resident in the bed you should first gather all needed supplies, then raise the bed to your waist level. She stated if you had to leave the resident unattended the bed should be put back down to the lowest position. She stated you should never turn your back on a resident when providing care as the resident could fall out of the bed and sustain an injury. The CNA stated she had learned this in CNA school, and it was important to know. Interview on 1/31/18 8:45 a.m. with CNA MM revealed she was R#4's caregiver for the day. She stated she was familiar with the resident's care needs. She stated the correct way to give the resident, or any resident a bed bath would be to first gather all needed supplies then raise the bed to waist level. She stated she was aware R#4 was a fall risk and could roll out of the bed an injure himself/herself if he was not supervised during bath time. She stated she learned how to give a bed bath and prevent falls in CNA school and various in-services presented at the facility. Interview with Licensed Practical Nurse (LPN) HH on 1/30/19 at 12:35 p.m. revealed to give safe care during a bed bath you should gather all your supplies first, raise the resident's bed up to waist level, and never turn your back on the resident. She stated your eyes should remain on the resident throughout the delivered care or else the resident could roll out of the bed and sustain an injury. Interview on 1/31/19 at 8:35 a.m. with the Infection Control Nurse revealed as he was doing his infection control rounds on 9/24/18 he saw the nurses putting R#4 back into the bed from the floor. He stated the resident had a large hematoma on the forehead. He revealed in the monthly clinical meetings, the facility required the clinical staff to attend because it was an opportunity to discuss clinical expectations. He went onto state it was an expectation staff have all their supplies prior to starting a resident bath and focus only on the resident during the task. He revealed R#4's fall with contusion could have been avoided. Interview with the Unit Manager of the 200 Hallway on 1/30/19 at 11:14 a.m. in the Administrator's Office revealed during the investigation it was determined CNA OO raised R#4's bed up to give a bed bath. The CNA then turned away from the resident and did not reposition the bed to the lowest level and the resident fell out of the bed onto the floor. She stated the CNA should not have turned away from the resident. Interview with the Director of Nursing Services (DNS) on 1/31/19 at 4:00 p.m. revealed it was everyone's job and a facility goal to keep the resident's safe. She stated prior to this incident, the facility had offered education on safe care and how to prevent falls. The DNS stated the CNA should not have turned away from the resident to gather supplies. Interview with the Administrator on 1/31/19 at 3:00 p.m. revealed she expected staff to do all they can do to protect the residents. She revealed the CNA had made an error when she delivered care to R#4. She stated she was ultimately in charge of the facility and maintaining resident safety was the responsibility of the entire staff. Record review revealed the facility had provided staff education regarding activities of daily living care (ADL) as well as fall prevention monthly. | 2020-09-01 |