cms_AL: 54

In collaboration with The Seattle Times, Big Local News is providing full-text nursing home deficiencies from Centers for Medicare & Medicaid Services (CMS). These files contain the full narrative details of each nursing home deficiency cited regulators. The files include deficiencies from Standard Surveys (routine inspections) and from Complaint Surveys. Complete data begins January 2011 (although some earlier inspections do show up). Individual states are provides as CSV files. A very large (4.5GB) national file is also provided as a zipped archive. New data will be updated on a monthly basis. For additional documentation, please see the README.

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rowid facility_name facility_id address city state zip inspection_date deficiency_tag scope_severity complaint standard eventid inspection_text filedate
54 ATHENS HEALTH AND REHABILITATION LLC 15016 611 WEST MARKET STREET ATHENS AL 35611 2019-08-29 580 D 1 1 39OM11 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, record review and review of a facility policy titled, Change in Medical Condition of Resident/Guest(s), the facility failed to ensure Resident Identifier (RI) #272's family/responsible party was notified of a new order written on 4/19/19, for [MEDICATION NAME] DR (Delayed Release) 125 MG (milligrams) sprinkle by mouth at hour of sleep. This deficient practice affected RI #272, one of 25 sampled residents. Finding Include: A facility policy title: Change in Medical Condition of Resident/Guest (s), with an effective date of 11/28/2016 revealed the following: .STANDARD: Notification . legal representative, or interested family member, should occur promptly, according to federal regulations, when there is a change in the resident/guest (s) condition, . *A need to alter treatment . to commence a new form of treatment . RI #272 was admitted on [DATE] with [DIAGNOSES REDACTED]. A review of RI #272 Physician order [REDACTED]. The orders also included an order for [REDACTED]. On 8/29/19 5:52 p.m., the surveyor conducted an interview with Employee Identifier (EI) #3, Registered Nurse Unit Manager/Supervisor. The surveyor asked EI #3 was there an order for [REDACTED].#3 how could she verify that an order had been given. EI #3 stated what she had been told by this company was that you do not have to have a written order, you can put verbal orders directly into the computer. The surveyor asked EI #3 when did the physician write the order. EI #3 stated she did not know why the physician did not hand write the order. The surveyor asked EI #3 was this a usual practice. EI #3 stated, not generally. The surveyor asked was the family/responsible party notified of the new order. EI #3 stated it did not look like they were notified. The surveyor asked EI #3 where would the evident be that family was notified if there were evident. EI #3 stated in the nurses notes. The surveyor asked EI #3 was there evident in the nurses notes. EI #3 stated there was no record of it. The surveyor asked EI #3 who would have been responsible for notifying the family. EI #3 stated the nurse that put the order in. The surveyor asked did RI #272 receive [MEDICATION NAME] the entire time he/she was at the facility. EI #3 stated yes, it looked like he/she got it because they (nursing) were signing off that he/she got it. The surveyor asked EI #3 was there a new order for additional [MEDICATION NAME] 20 MG to be given on 4/24/19 for three days. EI #3 stated yes, give [MEDICATION NAME] 20 MG tablet by mouth at noon daily times three days in addition to morning dose. The surveyor asked EI #3 why was there a new order for the additional [MEDICATION NAME] 20 MG on 4/24/19 to be given one everyday at noon for three days. EI #3 stated she did not know, she guest the resident had some [MEDICAL CONDITION]. The surveyor asked EI #3 where would there be evident that the family was notified of that new order. EI #3 stated the LPN (License Practical Nurse) that took the order off should have notified the family. The surveyor asked EI #3 where did she note it in her notes. The surveyor gave EI #3 a copy of the nurse's notes. EI #3 stated it did not look like there was a note. This citation is written as a result of the investigation of complaint/report #AL 292. 2020-09-01