cms_GA: 4693
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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4693 | SADIE G. MAYS HEALTH & REHABILITATION CENTER | 115542 | 1821 ANDERSON AVENUE NW | ATLANTA | GA | 30314 | 2016-08-19 | 323 | D | 1 | 0 | 0RHV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record review, staff interviews, and facility policy and procedure review, the facility failed to implement the policies and procedures for fall prevention for 1 resident (R5) out of 9 residents. Further, the facility failed to maintain a safe environment for the residents in one of four hallways ( D hallway cart) the medication cart drawer was broken and would not lock. Findings include: 1. R5 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The initial Minimum Data Set (MDS) assessment, Section J, dated 4/28/16 identified that the resident was at high risk for falls. R5's care plan dated 4/29/16, identified the resident to be at risk for falls due to the use of cardiovascular and psychotropic medication use. One of the approaches identified was to .maintain a safe environment: clutter free, free of spills . The Nurse's Notes dated 7/21/16 documented that R5 sustained a fall, .Heard resident screaming in hallway. Observed resident sitting on the floor in a puddle of water in front of air conditioning unit outside of room . The resident did not sustain an injury per review of the Nurse's Notes. R5's care plan was updated on 7/21/16 and stated that the resident sustained [REDACTED].enfluence (sic) spending time in common area . A review was conducted of the facility's incident report and it documented that the resident was .ambulating in hallway, observed resident sitting on the floor in a puddle of water in front of air conditioner unit . There was no further investigation identified on this document that showed that the facility evaluated the fall or evaluated the potential for future falls by the resident. An interview was conducted with the Director of Health Services (DHS) on 8/19/16 at 11:40 a.m. along with the Corporate Nurse. When asked if there were any supportive investigative documents on the fall that R5 sustained on 7/21/16, the DHS stated that the resident was incontinent of bowel and bladder and that the resident had a history of [REDACTED]. Per the DHS, R5 poured water on the floor on 8/18/16. When DHS and the corporate nurse were asked again if there was any investigation on the resident's fall of 7/21/16, the DHS, said no. The facility's policy and procedure titled, Occurrences with a revised date of 5/4/2016 revealed, .Occurrence hazards are physical features in the healthcare center property which results in an injury or has the potential for injury .Any event, accident or incident, on or off healthcare center property which results in an injury or has the potential for injury .Director of Health Services will be responsible to review each occurrence for thorough investigation, documenting the investigation in the patient/resident care software .Occurrence investigation and follow-up is a joint responsibility within the healthcare center . 2. During the initial tour of the facility on 8/18/16 at 10:30 a.m. nurses were observed conducting medication administration pass on the D wing of the facility. Observation of the medication cart revealed the top drawer was broken and could not lock. Inside the drawer were the following medications: [REDACTED]. Colace 100 mg tablets 1 bottle. Residue of crushed medication in plastic packages, Sodium Bicarbonate 650 mg, Carvedilol 6.23 mg, Amlodipine 10 mg, and Namenda 10 mg. Five residents were observed seated in wheelchairs in close proximity to the broken medication cart. During an interview with the Director of Health Services (DHS) at 8/18/16 at 10:55 a.m. she reported she was not aware the medication cart drawer was broken and after speaking to her charge nurse she learned the medication cart has been broken for 2 days. | 2019-08-01 |