cms_GA: 8160
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 |
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
8160 | CEDAR VALLEY NSG & REHAB CTR | 115436 | 225 PHILPOT STREET | CEDARTOWN | GA | 30125 | 2012-01-05 | 318 | D | 0 | 1 | I4YU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews and staff interviews, the facility failed ensure that a decline did not occur for two (2) residents (# 19 and #100) with limited range of motion from a sample of thirty-three (33) residents. Finding includes: 1. Record review for resident #19 revealed [DIAGNOSES REDACTED]. Further record review revealed physician's orders [REDACTED]. Review of quarterly Minimum Data Set ((MDS) dated [DATE], 8/24/11 and Annual MDS dated [DATE] revealed the resident was assessed as having no impairment to upper extremities only to bilateral lower extremities (BLE) Review of the restorative notes for November and December 2011 revealed PROM was being done to BUE, which was started 11/15/11 Interview with charge nurse EE conducted 1/4/11 at 2:15pm revealed the resident has bilateral hand contractures. Joint range of motion and mobility screening conducted 11/17/11 revealed that the resident had limited joint mobility effecting hip, knee, ankle, shoulder, elbow, wrist and fingers. The form indicated that here was no change for the last screening done 8/22/11. Observation conducted 1/4/12 at 3:20pm with restorative nurse CC revealed the resident was lying quietly in bed with her arms across her chest. Bilateral extensive hand contractures were noted. CC further indicated that the resident had been feeding herself up until the last several years ago buy holding the spoon, now she cannot even hold a spoon. 2. Record review for resident #100 revealed the resident was admitted to the facility July 7, 2006 and has [DIAGNOSES REDACTED]. Review of physician's orders [REDACTED]. Review of December physician's progress note revealed this resident is bed/chair bound, and has generalized weakness. The Quarterly Minimum Data Set ((MDS) dated [DATE] assessed the resident as having impairment on both sides for upper and lower extremities. The annual MDS dated [DATE] ROM was assessed the same as 10/21/11 quarterly. Review of restorative notes for December revealed PROM for all extremities started 12/31/11. Further review revealed previous restorative record dated March 2011 which indicated PROM was done to all extremities March 1- 22, 2011 and February 25, 26, and 27, 2011. There was no evidence that any further PROM was conducted until 12/31/11, nine (9) months later. Record review revealed a joint range of motion mobility screen conducted 10/21/11 which revealed limited mobility in hip, knee, shoulder, elbow and wrist but with no significant change from last screen conducted 8/23/11. During interview conducted 1/4/12 at 9:30am with restorative staff CC , she was asked why PROM was stopped after March 2011 and then resumed 12/31/11. She replied that PROM was only done for thirty days, not on a continuous basis. When asked about how would the facility prevent or assess decline if you stop and then resume months later, she indicated she was unaware of why PROM was done for 30 days then stopped. A further interview with CC conducted 1/5/12 at 3pm revealed that she was not aware of any reevaluation of residents ' PROM being conducted after 30 days. She indicated that she assesses residents quarterly. Review of facility policy Passive Range of Motion/Splint Program revealed that policy does not address performing PROM for only thirty (30) days or any evaluation after its completion. Observation conducted 1/5/12 at 2:45pm revealed the resident has very limited joint mobility on her hands. Her right hand was lying by her side with her fingers straight and she was using her left hand to rub her mouth. This observation revealed is able to use her hands per herself. | 2016-06-01 |