cms_GA: 5329
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 5329 | HERITAGE INN HEALTH AND REHABILITATION | 115597 | 307 JONES MILL ROAD | STATESBORO | GA | 30458 | 2015-10-28 | 272 | E | 1 | 0 | SGS711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to complete the facility's Comprehensive Falls Assessment form per facility policy to aid in the development of resident interventions related to falls for three (3) of three (3) residents reviewed. Review of the facility Falls Management at a Glance: Intent revealed the Falls program was an interdisciplinary approach to the management of patients at high risk for falls. The Goal was to be proactive in efforts to identify risk factors that reduce the frequency of falls and serious injuries. Program progress included a Comprehensive Falls Assessment to be completed on Admission, Readmission, Quarterly, Annually and as clinically indicated. Appropriate interventions were implemented on The Falls Intervention Plan (FIP) based on the findings from the Comprehensive Falls Assessment. The Director of Nursing (DON) and/or designee would ensure updates occurred for the FIP, 24 hour report and Accunurse. Review of the medical record for resident #1 revealed were was admitted in 04/2015 after a hospital stay for altered mental status and urinary tract infection. Other [DIAGNOSES REDACTED]. Resident #1 Required extensive assistance with transfers and walking. Further review revealed that no Comprehensive Falls Assessments completed on admission in (MONTH) (YEAR) with falls occurring on 06/20/2015 and 06/21/2015. Review of the medical record for resident #2 revealed admitted in (MONTH) of 2012. [DIAGNOSES REDACTED]. Further review revealed no Comprehensive Falls Assessments completed with Quarterly assessments dated 04/08/2015 and 07/11/2015 or Annual assessment dated [DATE]; with falls occurring 08/07/2015, 08/19/2015, 09/28/2015 and 09/29/2015. Review of Medical record for resident #3 revealed she was admitted in (MONTH) of 2014. [DIAGNOSES REDACTED]. She required supervision with transfers and walking. Further review revealed no Comprehensive Falls Assessment completed with Quarterly assessments dated 04/29/2015, 07/08/2015 and 08/18/2015; with fall occurring on 07/01/2015. Interview on 10/27/2015 at 5:19 p.m. the Director of Nursing (DON) revealed the Comprehensive Falls Assessment was completed by the Minimum Data Set (M DS) Coordinators in conjunction with the MDS schedule. If at risk, interventions were put into place on the FIP/careplan and were communicated with the Certified Nursing Assistants (CNAs) through Accumurse. Interview on 10/28/2015 at 6:30 a.m. with the Falls Program Coordinator revealed the Comprehensive Falls Assessment was to be completed quarterly and annually. The MDS Coordinator would post a schedule of assessments and the Comprehensive Falls Assessments were assigned to be completed by the floor nurse and were discussed in the care plan meeting. If it had not been completed prior to the care plan meeting, it would be completed at the meeting. The care plan would be reviewed for appropriate interventions if falls had occurred. Interview on 10/28/2015 at 12:45 p.m. with the DON confirmed the Comprehensive Falls Assessment tools were not completed on the residents #1, #2 or #3; however, she stated that falls were discussed per occurrence, during Patient at Risk (PAR) meetings and during Care plan Conferences. She was not sure why the tool was not being used. | 2018-10-01 |