cms_GA: 8148
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 |
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
8148 | BOLINGREEN HEALTH AND REHABILITATION | 115346 | 529 BOLINGREEN DRIVE | MACON | GA | 31210 | 2011-12-22 | 309 | D | 0 | 1 | BW4W11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to follow physician orders [REDACTED].#11) from a sample of thirty-seven (37) residents. Findings include: Review of the interdisciplinary progress note dated 12/16/11 revealed resident #11 was found lying on her back, on 12/15/11 at 3:15 p.m., on the floor beside her bed. An assessment was completed and no injuries were noted. However,the Physician Assistant (PA) was in the facility, notified, and assessed the resident. Neurochecks were ordered to be done per protocol for three (3) days. Review of the neurocheck worksheet revealed that neuro checks were to be done every fifteen (15) minutes for the first hour, every thirty (30) minutes for the second hour, every hour for six (6) hours, every four (4) hours for twenty-four (24) hours and then every shift up to seventy two (72) hours. Continued review revealed that after the first hour a summary should be written in the Inter Disciplinary Team (IDT) notes of the findings during neuro checks and also at the end of each shift. Review of the neurocheck worksheet for resident #11 dated 12/15/11 revealed that after the second hour, there was no evidence that the neurochecks were completed as ordered. The level of consciousness (LOC), pupils equal, round, reactive to light and accommodation (PERRLA) and hand grip were not summarized in the IDT notes, only that neurochecks were in progress or neurochecks x twenty four (24) hours on 12/16/11. Review of the IDT notes for 12/17/11 revealed no evidence of neurochecks being done. Interview with the Director of Nursing (DON) and Nurse Consultant BB on 12/21/11 at 11:15 a.m., revealed that that there was no evidence that the neurochecks were completed as ordered. Continued interview revealed that the neuro check sheet was only a worksheet and she expected the nurses to write a summary in the interdisciplinary progress notes for the seventy-two (72) hours that the neurochecks were ordered. | 2016-06-01 |