cms_GA: 4680

In collaboration with The Seattle Times, Big Local News is providing full-text nursing home deficiencies from Centers for Medicare & Medicaid Services (CMS). These files contain the full narrative details of each nursing home deficiency cited regulators. The files include deficiencies from Standard Surveys (routine inspections) and from Complaint Surveys. Complete data begins January 2011 (although some earlier inspections do show up). Individual states are provides as CSV files. A very large (4.5GB) national file is also provided as a zipped archive. New data will be updated on a monthly basis. For additional documentation, please see the README.

Data source: Big Local News · About: big-local-datasette

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rowid facility_name facility_id address city state zip inspection_date deficiency_tag scope_severity complaint standard eventid inspection_text filedate
4680 PRUITTHEALTH - VIRGINIA PARK 115531 1000 BRIARCLIFF ROAD NE ATLANTA GA 30306 2016-08-24 514 D 1 0 3CUI11 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review the facility failed to maintain accurate and complete clinical records for 2 of 9 sampled residents (R108, R57). Findings include: 1. Review of the closed clinical record revealed Resident (R) 108 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R108 had 13 falls within one year. Review of the Care Plan dated 4/19/16 indicated R108 had interventions put in place after each of the falls. Review of 9 incident reports dated 2/02/16 through 4/19/16 revealed the staff did not document which interventions, if any, were in place at the time of R108's falls. During an interview on 8/23/16 at 8:08 a.m. the Treatment Nurse said she administered the first aid after R108's last fall. She said the nurses did not normally document which interventions were in place at the time of a resident's fall. During an interview on 8/23/16 at 8:45 a.m. the Director of Nursing (DON) said the nurses referred to the resident's care plan and the nurse aides referred to an activities of daily living (ADL) guide in order to know which interventions should be in place for that resident. The DON said the staff did not document in the incident report or in nurse's notes what interventions were in place at the time of a resident's fall. The DON said she could see how it would be beneficial to document the interventions in order to know if they were utilized and if they were effective or not. She said that was not the current procedure for the facility. 2. R57's record was reviewed on 8/22/16 at 11:05 a.m. R57's [DIAGNOSES REDACTED]. Review of the resident's physician order [REDACTED]. Foley catheter care was to be completed every shift. Review of an Admission/Nursing Observation Form, dated 5/17/16, completed upon readmission to the facility, indicated Bladder Resident/Family reports: Brief (marked with an X) and Hx (History) of UTI (Urinary tract infection) Indwelling Catheter DX (diagnosis) HX UTI Size 16. R57 was observed on 8/23/16 at 9:00 a.m., during wound care with Licensed Practical Nurse (LPN) 18 and Nurse Aide (NA) 33 present, lying in bed. NA 33 and LPN 18 removed the resident's incontinence brief. The catheter was observed to be inserted into the resident's scrotum next to his penis. When asked, LPN 18 indicated she had not seen this before and this should have been reported to the nurse. She indicated the catheter was not in the resident's penis but was going through the area to the side of the penis. NA 33 indicated she had not seen where the catheter was inserted on the resident before now. Further review of the resident's record lacked documentation related the placement of the catheter (Cross Reference F315). R57's catheter was observed on 8/23/16 at 10:03 a.m., with the Director of Nursing (DON) present. The DON indicted a urologist had surgically inserted the catheter. She indicated she would have to look for documentation of the catheter. During an interview on 8/23/16 at 12:55 p.m., the DON indicated she was still looking for information for the resident's catheter. During an interview on 8/23/16 at 2:00 p.m., the DON indicated she was trying to get information from the hospital related to the catheter. She indicated the catheter had been surgically inserted when he was in the hospital before he had been readmitted to the facility on [DATE]. During an interview on 8/23/16 at 2:05 p.m., the Corporate Nurse Consultant indicated she was not sure what was going on with R57's catheter. She indicted it was not located in the normal place and she was not able to find any documentation in the resident's record related to the catheter location. 2019-08-01