cms_GA: 8211
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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8211 | REHABILITATION CENTER OF SOUTH GEORGIA | 115676 | 2002 TIFT AVENUE NORTH | TIFTON | GA | 31794 | 2012-11-01 | 318 | D | 0 | 1 | GCPU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews and record reviews, it was determined that the facility failed to provide range of motion exercises for two residents (#68 and #2) from a sample of six residents with limitations in range of motion from a total sample of 39 residents. Findings include: 1. Resident # 68 had [DIAGNOSES REDACTED]. The nursing staff coded the resident on his/her 5/21/12 and 8/17/12 quarterly Minimum Data Set (MDS) assessments as having functional limitations in both of his/her upper and lower extremities (arms and legs). However, staff did not develop a care plan for the resident which included his/her problem of having limited range of motion. During an interview on 10/29/12 at 3:05 p.m., licensed nurse DD said the resident had contractures of his/her upper and lower extremities. The resident was observed on 10/30/12 at 10:44 a.m. to have been lying in bed in the fetal position. On 10/31/12 at 1:20 p.m., while the resident was lying in bed, Certified Nursing Assistant (CNA) AA attempted to extend the resident's legs but was not able to extend them more than 90 degrees. Although the CNA extended the resident's right arm to almost 180 degrees, the resident grimaced when she attempted to extend the resident's left arm. Licensed nurse DD stated that the CNAs, who were assigned to give residents' their care, had each resident's care information documented in the Activity of Daily Living (ADL) notebook . She said that the CNAs signed off in that notebook to record the care provided each day for that resident. There was an entry printed on resident's October ADL form ADL Information: Range of motion (ROM) - splint application. See Restorative book. There was no documentation for any day in October, 2012 to indicate that a CNA had signed off to record having provided ROM or splint application for the resident. There was not an assignment sheet for resident #68 in the restorative nursing services notebook to indicate that restorative nursing staff was providing care for him/her. During an interview on 10/30/12 at 4:00 p.m., restorative nursing CNA BB stated that the resident was not being provided restorative nursing care and could not remember when it had last been provided to him/her. There was documentation in the resident's medical record that restorative nursing services for range of motion exercises and splinting began in February 2012. According to the April 2012 Restorative Nursing Care records the restorative nursing CNA was supposed to provide range of motion exercises to all of the resident's extremities for 15 minutes or more, and to apply an extension brace on his/her right lower extremity and bilateral hand splints seven times a week. The last documentation that the resident was provided restorative services was on 4/19/12. There was no evidence since 4/19/12 that the facility had provided range of motion exercises and splinting for the resident to prevent further contractures. The resident was observed on 10/31/12 at 7:45 a.m. seated in a reclining wheelchair in the dining room. The resident did not have an extension brace on his/her right leg or splints on his/her hands. At 9:30 a.m. on 10/31/12, CNA AA, who said that she provided care for the resident, said that the resident used to have splints for his./her legs but did not now . She said that she did not remember when they were stopped. During an interview on 10/31/12 at 10:50 a.m., registered nurse CC said that she was not aware of resident #68 using any splints or braces. 2. Resident #2 had [DIAGNOSES REDACTED]. Licensed nursing staff coded the resident on his/her 7/30/12 quarterly Minimum Data Set assessment as requiring extensive assistance with dressing, transfers, bed mobility and personal hygiene, and as totally dependent for toilet use. Staff coded resident #2 as having functional limitations in range of motion on one side of his/her upper and lower extremity. According to the physical therapy services records, the resident was discharged from skilled therapy services on 8/24/12 and placed in the restorative nursing program for range of motion exercises. Review of the restorative nursing notes revealed evidence that the resident had been provided those services from 8/24/12 through 9/29/12. However, there was no evidence that nursing staff had provided range of motion exercises to the resident since 9/29/12. The resident was observed on 10/30/12 at 3:45 p.m. sitting in a wheelchair with his/her left hand in a curled position in his/her lap. During an interview on 10/31/12 at 2:45 p.m., restorative nursing services CNA EE explained that resident #2 had been removed from the restorative services due to casework overload. RCNA EE stated that resident #2 was supposed to have been assigned to the floor certified nursing assistants (CNAs) for range of motion exercises. However, in an interview on 11/01/12 at 11:52 a.m., the Director of Nurses confirmed that the facility failed to assign the resident to the floor CNAs to provide range of motion exercises. | 2016-06-01 |