cms_GA: 581
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 |
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
581 | MANOR CARE REHABILITATION CENTER - MARIETTA | 115283 | 4360 JOHNSON FERRY PLACE | MARIETTA | GA | 30068 | 2017-09-21 | 279 | D | 0 | 1 | N4J711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interviews, the facility failed to ensure the revision of care plans for non-pharmacological interventions occurred for three of six residents (R#49, R#71, and R#159) reviewed. Findings include: 1. Per the electronic clinical record review, R#159 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A medical record Care Plan most recently revised on 1/26/16 identified R#159 was at risk for adverse effects related to the use of an anxiolytic ([MEDICATION NAME]). There was no mention to offer non-pharmacological interventions prior to the use of the as needed (PRN) anxiolytic. Another most recently revised Care Plan on 11/27/16 identified R#159 enjoyed activities and noted the resident had cognitive and communication impairments related to dementia. Under the interventions it was documented to offer R#159 1:1 visits, participation in group activities of interest, preferred food items, television in bed, and family visits when available. Again, this section of the plan of care in the medical record failed to identify if these activities were attempts to reduce R#159's anxiety prior to the administration of an anxiolytic medication. 2. Per the electronic clinical record review, R#49 was admitted to the facility on [DATE]. A medical record review of the Care Plan dated as revised on 6/8/17 identified R#49 was at risk for adverse effects related to the use of an antipsychotic ([MEDICATION NAME]). There was no mention to offer non-pharmacological interventions prior to the use of the as needed (PRN) antipsychotic. Another reveiw of the Care Plan dated as revised on 9/6/17, identified R#49 enjoyed activities and noted the resident had cognitive and communication impairments related to dementia. Under the interventions it was documented to offer R#49 .redirection and diversion as needed. Again, this section of the care plan failed to identify if the redirection and diversion, were attempts to reduce R#49's anxiety prior to the administration of an antipsychotic medication. 3. Per the electronic clinical record review, R#71 was admitted to the facility on [DATE]. A medical record review of the Care Plan dated as initiated 3/23/17, identified R#71was at risk for adverse effects related to use of a PRN antianxiety medication. There was no mention to offer non-pharmacological interventions prior to the use of the PRN antianxiety. In another Care Plan dated as revised 6/16/17, identified R#71 was not interested in attending activities. The intervention noted was to .redirect the resident as needed due to cognitive impairment. Again, there was no mention if this redirection was to be done prior to the administration of the PRN antianxiety. An interview was conducted with the Minimum Data Set (MDS) Coordinator on 9/20/17 at 11:23 a.m., The MDS Coordinator stated she completes the assessments and revises the care plans. She stated she typically updates and any changes on a resident would be discussed in the morning meetings. The MDS Coordinator further stated the floor nurses have the capability to update resident care plans as well. The facility policy entitled, INTERDISCIPLINARY CARE PLANNING dated 11/16 noted, The patient's care plan is a communication tool that guides members of the interdisciplinary healthcare team in how to meet each individual patient's needs. It also identifies the types and methods .Once the care plan is developed, the staff must implement the interventions identified in the care plan. These may include, but is not limited to: administering treatments and medications .As the care plan is implemented, members of the interdisciplinary team need to evaluate whether the interventions are effective or whether the care plan needs to be revised . | 2020-09-01 |