cms_GA: 4545
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 4545 | PIONEER HEALTH OF CENTRAL GEORGIA | 115564 | 712 PATTERSON STREET | BYROMVILLE | GA | 31007 | 2016-12-10 | 279 | D | 0 | 1 | QBL111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to ensure a comprehensive plan of care that accurately reflected the status and needs of the resident was created for three residents (R#32, R#42 and R#56) out of 45 sampled residents. Specifically, R#32's care plan did not reflect the services provided by hospice or instruct the facility staff how to coordinate their services with the hospice provider and R#42's care plan did not reflect nutrition interventions to address weight loss. Findings include: 1. R#32 was admitted to the facility on [DATE]. The 12/16/14 Care Plan, reviewed 10/19/16, documented, I have chosen to receive hospice care. The goal was for the resident to remain comfortable throughout hospice care. The approaches included: Contact (hospice service) as indicated .Coordinate care with Hospice Team .Coordinate with the Hospice Team to assure resident experiences as little pain as possible .Provide resident and family with grief and spiritual counseling if desired. The Care Plan did not document what services were provided by hospice, how often the hospice providers visited the resident, and how the facility staff could communicate and coordinate care with the hospice service. The hospice's plan of care was not available in the resident's record, nor were any hospice documents except for the (Name of Hospice) Communication Log. On 12/10/16 at 8:42 a.m., the Director of Nursing (DON) provided all hospice documentation from (MONTH) (YEAR) to present, which had to be faxed over from the hospice service's main office. Cross-reference F309: Care and Services regarding the coordination of hospice services. On 12/10/16 at 8:57 a.m., the MDS Coordinator (MDSC) stated she typically would take the hospice care plan and combine in the facility's 'Care Plan;' I do not typically include details related to what specific services hospice provides, how often they visit, etc. because I think they adjust it based on the individual needs of the resident .I do not put the hospice care plan in the chart. When asked how the staff would know what services were provided by hospice and how often the hospice providers visited, she stated, The nurses usually come once a week and the (aides) usually come three times a week. She agreed this information had not been communicated with the staff via the R#32's care plan. On 12/10/16 at 9:24 a.m., the DON stated it was her expectation that hospice documentation be left in the chart and the hospice care plan be accessible to staff to facilitate coordination of care between the facility staff and hospice. 4. R#42 was admitted to the facility on [DATE]. According to the Admission Record, his [DIAGNOSES REDACTED]. Review of a Nutrition assessment dated [DATE] indicated the resident was 72 or 6' tall. The resident's ideal weight range was from 160-196 lbs. The current (MONTH) monthly physician's orders [REDACTED]. According to the Weights and Vitals Summary, R42's weights, the resident experienced a 24 lb, 11.9% unplanned, significant weight loss in 3 months from 201.5 lbs on 9/8/16 to his most current weight of 177.5 lbs on 12/5/16. Cross refer to F325. The resident was observed on 12/5/16 at 11:45 a.m.; he was noted to be tall and lean in appearance. The resident was not observed in the dining room at meals, with food in his room, or eating or drinking at any time during the survey. The Medical Director and R#42's Attending Physician was interviewed on 12/9/16 at 4:08 p.m. and stated, although he did not have the resident's information at his disposal at the time of the call, he saw the resident in the hospital when the feeding tube was inserted. He stated the resident's intake was not adequate and he had already lost some weight at that point. He stated the resident's reduced intake led to his weight loss. The resident's care plan was reviewed. Although the facility developed a care plan to address tube feeding, the care plan did not include weight loss. The problem of significant, unplanned weight loss had not been identified on the care plan; no interventions to address the resident's weight loss or calorie deficit were care planned. 5. R#56, [AGE] years old, was admitted to the facility on [DATE]. Review of the [DIAGNOSES REDACTED]. Review of the 4/1/16 Admission Minimum Data Set (MDS) indicated R#56 did not speak ([DIAGNOSES REDACTED]. R#56 was either independent or required supervision with activities of daily living (ADLs) including bed mobility, transfers, and walking. Review of incidents reported to the state survey agency revealed the resident was involved in 7 altercations with other residents between 4/ 11/16 and 8/15/16. In 4 of the incidents, R#56 was the aggressor towards other residents. In 3 others, he was the victim. Cross refer to F323 for incident information. The resident was observed during the survey 12/5/16 - 12/10/16. There were times when R#56's behavior was problematic; he was observed to lack boundaries and be unaware of the personal space of other individuals. Furthermore, the resident was observed in an altercation in which he was a victim of physical aggression by R#39 and he also was an instigator of physical aggression towards one of the surveyors during the survey. Cross refer to F323 for detailed observations. Staff interviews revealed the resident had a number of behaviors that annoyed other residents such as violating the personal space of other residents, hitting when residents or staff got too close to him or for unknown reasons, and exhibiting behaviors known to agitate other residents such as taking food off their plates or repeatedly going into their rooms, and adjusting the blinds/looking out the windows. Cross refer to F323 for details of interviews. Although the first incident of resident to resident altercation occurred in less than a month of admission (on 4/11/16), the resident's care plan for behaviors was not adequate in scope and detail to address his array of behaviors, which were at times significant. The problems identified on the care plan indicated the resident exhibited inappropriate sexual behaviors, head banging, aggressiveness, physical abuse/altercations, vomiting, laying and sleeping on the floor, banging holes in the walls, tearing items off the walls, and wandering. The goal was for the resident not to harm himself or others. Interventions in full read, -Administer medications as ordered. Observe for effectiveness and side effects. -Encourage to attend activities of choice. -Give resident multiple choices for care and activities when able. -Notify MD as indicated. -Observe for and s/s (signs and symptoms) of resident posing danger to self and others. Observe for an increase or change in behaviors. -Provide physical and verbal cue to alleviate anxiety, give positive feedback, assist as able, encourage seeking out a staff member when agitated. -psych consult as indicated. -When resident becomes agitated, intervene before agitation escalates, guide away from source of distress, approach calmly and friendly, attempt to distract in positive conversation. If continues to be agitated/aggressive towards staff walk away calmly and approach later. -Staff to remove from dining room when intruding on others. -Encourage him to play with his toys. Offer him toys during the day. -Give PRN as ordered for MD for agitation. The care plan failed to identify and address the problems of R#56 getting into the personal space of other residents, repeated wandering into specific residents' rooms, difficulty with redirecting him, his propensity to hit when residents or staff came too close, specific interventions for the dining room such as sitting at a table with staff present, serving him first and assisting him out of the dining room after meals, and need for increased supervision. | 2019-09-01 |