cms_AL: 30
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 |
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
30 | EASTVIEW REHABILITATION & HEALTHCARE CENTER | 15014 | 7755 FOURTH AVENUE SOUTH | BIRMINGHAM | AL | 35206 | 2018-01-25 | 656 | D | 0 | 1 | I9JH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview and a review of a facility policy titled Care Plans the facility failed to ensure a care plan was developed for fall prevention on resident identifier (RI) #285. This deficient practice affected one of 18 sampled residents whose Care Plans (CP) were reviewed. Findings Include: A review of a facility policy titled Care Plans with a revised date of 09/2009 documented the following: . PURPOSE: Plans of Care are developed by the interdisciplinary team, to coordinate and communicate the plan of care for the resident. STANDARD: According to federal regulations, the facility develops a comprehensive plan of care for each resident . to meet a resident's medical, nursing and mental/psychosocial needs . PR[NAME]ESS: I. Entry Record a) . assessment must be completed on every admission . no later that the entry date Plus 14 calendar days . II. a) The comprehensive assessment is completed no later that 14 days of admission . 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 06:00 PM, RI #285 told the surveyor he/she had a fall on 01/19/18 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 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 there was always two staff members, but this time there was only one staff member. On 01/25/2018 at 8:30 AM, RI #285's Fall Risk assessment dated [DATE] was reviewed on the computer and it was 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 which was hand signed and dated 01/25/2018 (no time was documented). RI #285's care plan (CP) was reviewed and no fall CP was found. On 01/25/2018 at 9:15 AM, EI #2 was asked when was the Fall Risk Assessment filled out. EI #2 said at 9:00 a.m., on 01/25/2018 and she had filled it out. 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 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 it hand signed by herself and EI #1. EI #2 said because it was never done initially. EI #2 was asked who was responsible to fill the Fall Risk Assessment out. EI #2 said, the admitting nurse. EI #2 was asked if RI #285 had ever had any falls at the facility. EI #2 said, yes sometime last week with no injury. EI #2 was asked how did RI #285 fall. EI #2 said she did not know. EI #2 was asked what interventions were in place for falls upon admission. EI #2 said, she did not know. EI #2 was asked if there was a fall CP for RI #285. EI #2 said, no. RI #285's 12/28/17 MDS documented RI #285 required two person assist with transfers. EI #2 was asked did the MDS address if RI #285 was at risk for falls. EI#2 said, no it did not. EI #2 was asked was fall CP put in place after RI #285 fell on [DATE]. EI #2 said, no. EI #2 was asked should RI #285 been CP for falls. EI #2 said, yes. | 2020-09-01 |