cms_GA: 4496
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 |
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4496 | SIGNATURE HEALTHCARE OF BUCKHEAD | 115110 | 54 PEACHTREE PARK DRIVE N.E. | ATLANTA | GA | 30309 | 2016-09-02 | 282 | G | 1 | 0 | NU4N11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to ensure residents were provided with interventions as outlined on the care plan for 1 of 12 sampled residents (R4). Resident (R) 4 sustained injuries during 2 falls at the Nursing facility. One fall resulted in hospitalization (Cross Reference F323). Findings include: Record review for R4 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. The 3/7/16 admission Minimum Data Set (MDS) assessment indicated the resident had no falls in the 6 months prior to admission, required extensive assistance of two for transfers, and scored 12 out of 15 on the Brief Interview for Mental Status (BIMS) - meaning moderate cognitive impairment. Review of the 3/9/16 care plan indicated the resident was at risk for falls related to impaired balance, amputations and vision loss. Interventions included to provide call light within reach, keep area free of clutter, staff to assist with transfers, side rails use as an enabler, provide adequate lighting and report falls to physician and responsible party. Review of the electronic skilled nurses' notes with the Staff Development Coordinator (SDC) revealed a nurse's note dated 3/23/16 timed at 4:15 p.m. indicating R4 was found on the floor. The care plan was updated on 3/23/16, indicating that the resident's fall was related to her leaning over in her wheelchair to pick up her remote control and an intervention was added instructing maintenance to assess the resident's wheelchair for proper functionality and to keep items within reach. Interview with the Maintenance Director on 9/1/16 at 12:30 p.m. regarding his assessment of the resident's wheelchair revealed he had a Maintenance Log Book kept at each nurses' station. He said the Maintenance Book was checked frequently. The Maintenance Director said staff were instructed to document any maintenance request in the book, but staff were inconsistent with documenting their requests. He further reported most staff would simply tell him what needed to be fixed while passing in the hallways or elevator. When asked if he ever assessed a wheelchair on behalf of R4, he reported he remembered the resident when she was in the facility but did not recall a request to assess the wheelchair. He further stated he and the therapy department worked together on wheelchairs and he would double check the Maintenance Log Book. On 9/1/16 at 12:40 p.m. the Maintenance Director reported he was never informed of a request to look at R4's wheelchair and never assessed her wheelchair for proper functioning; the resident's care plan was not implemented. | 2019-09-01 |