cms_GA: 4130
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 4130 | RIVER BROOK HEALTHCARE CENTER | 115635 | 390 SWEAT STREET | HOMERVILLE | GA | 31634 | 2017-07-20 | 318 | D | 0 | 1 | CSOQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews, the facility failed to provide maintenance services for one (1) resident after stopping Range of Motion (ROM) services for one (1) resident with a contracture without a physician's orders [REDACTED]. Findings included: Observations: On 7/18/2017 2:21p.m., resident was observed lying in bed awake. Resident was observed to have a contracture of her upper extremity and did not have a splint device. On 7/19/2017 8:34 a.m., resident was sitting up in a Geri-chair in the solarium. Resident did not have a splint device in place. On 7/19/2017 2:48 p.m., resident was sitting up in a Geri-chair in the solarium. Resident was awake, but no splint device in place. Record Reviews: Review of resident #30's care plan on 7/19/2017 at 1:07 p.m., resident's care plan did not address resident's contracture. Per review of resident's most recent MDS for 6/16/17, resident is not coded for left upper extremity impairment. MDS was not coded for hand contracture, but was coded for leg contracture which resident did not have did not have. Interviews: On 07/17/2017 02:31 p.m., staff HH reports that resident has a contracture of her upper extremity and does not have a splint device, and does not receive restorative services due to there not be a restorative nurse. On 07/19/2017 2:48:17 p.m., interviewed staff DD who confirmed that resident does have a contracture of her upper extremity. She also reviewed resident's care plan that was last updated on 5/29/2017, and reported that the care plan did not address resident's contracture. Staff explained that she did not find any information in the care plan to address resident's contracture. She explained that her expectation was for nursing staff to evaluate residents, make a referral to therapy for an evaluation, and forward that information to the physician. Her expectation for resident to be treated according to physician's orders [REDACTED]. On 07/20/2017 9:08 a.m., interviewed MDS Coordinator, who stated that resident is not currently receiving maintenance services. She stated that there was documentation for (MONTH) and (MONTH) of (YEAR), for nursing restorative program for this resident, but no documentation for the months of May, June, July. She stated that resident was evaluated on 6/6/17, by therapy department. Staff also explained that resident is supposed to be fitted on 7/20/17, for a new splint, but has not been receiving ROM in the meanwhile. Staff reported that restorative services were discontinued due to there being issues with restorative staff. However, resident should have received maintenance services and there should have been an order to discontinue ROM, but there is not one. Staff reports that there was not an order to discontinue ROM for resident and she could get a letter from the doctor. She reported that resident's contracture was not coded correctly on the MDS by herself and that she would correct. It was coded as lower extremity where it should have been her left wrist. She reported that resident's contracture is not addressed on care plan. On 07/20/2017 10:15 a.m., interviewed staff II, stated that the physical therapy was taken over by a new company and residents were reassessed. Resident is being screened on 7/20/17, after being added to the list on 7/19/17. | 2020-04-01 |