cms_AL: 29
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 |
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
29 | EASTVIEW REHABILITATION & HEALTHCARE CENTER | 15014 | 7755 FOURTH AVENUE SOUTH | BIRMINGHAM | AL | 35206 | 2018-01-25 | 636 | D | 0 | 1 | I9JH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, interview with staff and review of a facility policy titled ADMINISTRATIVE POLICY, the facility failed to ensure Resident Identifier (RI) #285's fall risk assessment was completed upon admission. This deficient practice affected one of one residents investigated for falls. Findings Include: A review of a facility policy titled, ADMINISTRATIVE POLICY with a revised date of 10/2013 documented the following: . PURPOSE: Residents are assessed, . to identify care needs and to develop a plan of care. STANDARD: According to federal regulations, the facility conducts initially . a comprehensive, accurate . assessment of each resident's functional capacity . RI #285 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #285's 14 day assessment Minimum Data Set (MDS) with an Assessment Reference Date of 12/28/2017 revealed RI #285's Brief Interview for Mental Status score of 7, indicating cognition was severely impaired. Section G of the MDS, documented RI #285 required two plus person physical assist with transfers. On 01/24/18 at 6:00 PM, RI #285 told the surveyor he/she had a fall on 01/19/2018 when going to the bathroom with one staff member assisting him/her. RI #285 said he/she hurt his right side and hit his/her upper right forehead. He/she said he/she had pain to the right side of his/her abdominal area. RI #285 said an X-ray was done. RI #285 said he/she had tennis shoes on and the nurse took him/her by wheelchair into the bathroom and when he/she was trying to get back into the wheelchair from the toilet he/she fell . RI #285 said he/she was told there were no fractures. RI #285 said usually with his/her transfers that there is always two staff members, but this time there was only one staff member. On 01/25/2018 at 08:30 AM, RI #285's fall risk assessment dated [DATE] was reviewed on the computer and observed to be blank. The surveyor asked for a copy of the fall risk assessment. Employee Identifier (EI) #1, Registered Nurse (RN) Director of Nursing (DON) and EI #2, RN, MDS Coordinator provided a filled out/completed fall risk assessment hand signed and dated 01/25/2018 (no time was documented). On 01/25/2018 at 9:15 AM, EI #2 was asked when was the fall risk assessment filled out. EI #2 said she had filled it out on 01/25/2018 at 9:00 AM. EI #2 was asked if the fall risk assessment had been completed on admission. EI #2 said, no and this was the first fall risk assessment done on RI #285. EI #2 was asked if the fall assessment was completed in the computer, why was it not signed in the computer. EI #2 said because she wanted to talk to the person who initially did the assessment. EI #2 was asked why was the fall assessment hand signed by herself and EI #1. EI #2 said, because it was never done initially. EI #2 was asked who was responsible to complete the . Fall Risk Assessment. EI #2 said, the admitting nurse. | 2020-09-01 |