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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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1 | A.G. RHODES HOME WESLEY WOODS | 115002 | 1819 CLIFTON ROAD, N.E. | ATLANTA | GA | 30329 | 2019-02-14 | 656 | G | 0 | 1 | PXEL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record reviews and review of the facility policy titled, Care Planning - Interdisciplinary Team the facility failed to follow the care plan for one resident (R), #49. Actual harm was identified when R#49 suffered a midline laceration to the forehead and a [MEDICAL CONDITION] (Cervical) vertebral body requiring the use of a C-spine collar when she fell from her bed after being left unattended during a bed bath on 12/15/18. Additionally, the facility failed to develop a care plan for one Resident (R#94) for the use of a travel pillow for neck positioning. The sample size was 26 residents. Findings include: Review of the facility's policy titled Care Planning - Interdisciplinary Team reviewed on 3/1/18 noted: 1. A comprehensive care plan for each resident is developed within seven (7) days of completion of the resident assessment (MDS (Minimum Date Set)); 2. The care plan is based on the resident's comprehensive assessment and is developed by a care planning/interdisciplinary team. The policy did not include additional information regarding the development and implementation of resident care plans. 1. Review of the clinical record for R#49 revealed that the resident had the following [DIAGNOSES REDACTED]., [MEDICAL CONDITION] (left eye) and depression. Review of the Annual MDS, for R#49, dated 9/5/18 and review of the Quarterly MDS dated [DATE] revealed that the resident was assessed to be severely cognitively impaired, had physical and verbal behaviors directed towards others for one to three days during the assessment period. Review of Section G of this MDS documented that during this assessment period the resident was assessed to be dependent on staff for bathing requiring two plus person assist for bathing. R#49 had no impairment of the upper or lower extremities. Continued review revealed during this assessment period the resident had no falls and did not utilize any restraints or alarms. Review of the Fall care plan for R#49 last reviewed on 1/24/19 revealed the resident was a fall risk and required extensive to total assistance for Activities of Daily Living (ADLs). Pertinent interventions in place at the time of the resident's fall on 12/15/18 included the following: to assist with all ADLs, total transfer assist with Hoyer lift, floor mat at bedside, assist rails x 2; Broda chair when out of bed for comfort and positioning; and to keep bed in low position. Review of the Behavior care plan for R#49 last reviewed on 1/24/19 revealed that R#49 had behaviors - at risk for complications/side effects r/t (related to) use of antipsychotic and other mood stabilizing medication use. The interventions documented that if resistive/combative behavior was noted, leave R#49 alone and return when safe to do so/provide additional assist as needed. Review of a handwritten statement dated 12/21/18 written by CNA FF documented the following: On 12/15/18 at 10:45 a.m., I (CNA FF) entered room [ROOM NUMBER]. I began washing R#49's upper body and during the process she was fighting. She was yanking on the face towel and shirt. She punch at me and hit the right bedrail. I let her head down and lifted the right bedrail up and begin peri care. I turned her (R#49) to her left side to clean her bottom. She continue swinging her right arm backward towards me and pushing back. I felt that I could not clean her well, so I place her on her back. I went to pull right bedrail back down (meaning put the siderail in place) and R#49 grabbed it and begin shaking and punching it. I left it up (meaning that the siderail was not in place) and walked to the doorway and called for help. While I was standing in the doorway I heard a bang and when I turned around R#49 was laying on her back on the floor. I went towards her and yelled for the nurse. Signed by CNA FF. (sic) During an interview at the nurses' station on 1/30/19 at 11:55 a.m. with Registered Nurse Charge Nurse AA on 12/15/18, revealed that CNA FF told Registered Nurse AA that R#49 was combative so she (CNA FF) went to the resident's door to ask for help and when she turned back around the resident was on the floor. CN AA said that even if CNA FF felt like she had to go get someone, she should have made sure the bed was lowered as indicated in R#49's plan of care. During an interview at the nurses' station on 1/30/19 at 3:20 p.m. with CNA EE, CNA EE revealed that it usually required two staff to care for R#49. When asked about steps to take when the resident became combative during care, CNA EE said staff were supposed to wait until she calms down and then try to give care later. Telephone interview on 1/30/19 at 4:43 p.m. with CNA FF revealed on 12/15/18 the CNA FF was providing care to R#49 when the resident became aggressive. CNA FF said the resident and she played tug of war with the face towel while CNA FF washed the resident's upper extremities. According CNA FF, R#49 was striking out at the CNA FF and also punched the side rail with her right fist. Continued interview with CNA FF revealed that she did not re-approach the resident as indicated in her care plan and did not use the call light to seek help from other staff. During a follow-up interview at the nurses' station on 1/31/19 at 9:58 a.m. with Registered Nurse Charge Nurse AA revealed that the she thinks the resident's care plan called for one person for receiving care in bed and two people if resident is combative. Cross Reference F689 2. Review of the clinical record for R#94 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set (MDS) assessment for R#94 dated 1/8/19 revealed R#94 was severely cognitively impaired and required extensive to total assistance of one to two staff persons for all activities of daily living (ADLs). During this assessment period, R#94 received occupational therapy (OT), passive range of motion (PROM), and splint/brace assistance. Review of the Task tab printed from the electronic record for R#94 on 1/31/19 revealed Restorative staff was to provide R#94 with Passive Range of Motion (PROM) to the left hand six times per week for 15 minutes for each treatment and was to apply a splint/brace to her left hand for up to six hours - six times per week. The Task tab did not list the use of a travel neck pillow to be used for proper head positioning. Review of the comprehensive care plans for R#94 last reviewed on 1/12/19 revealed that there was not a plan of care developed to address proper neck/head positioning. Review of the Occupational Therapy (OT) Discharge Summary for R#94 dated 1/11/19 revealed one of the discharge recommendations was to continue to use cervical travel pillow when in bed and in Broda chair. Review of an Interdisciplinary Communication Memo for R#94 dated 1/11/19 completed by OT BB documented the following: Continue to use cervical travel pillow when in bed and Broda chair to maintain appropriate head positioning. Observation of R#94 in her room on 1/28/19 at 10:55 a.m. revealed that R#94 was lying in her bed with the head of the bed (HOB) elevated approximately 30 degrees. R#94 had a travel neck pillow around the back of her neck and the resident's head was bent forward and to the right near her shoulder with the resident's chin touching her chest as she slept. Interview at the nurses' station on 1/30/19 at 12:06 p.m. with Registered Nurse Charge Nurse AA revealed that R#94 used the travel neck pillow for positioning and for comfort. Interview on 1/30/19 at 3:50 p.m. with the Director of Nursing (DON) and Minimum Data Set (MDS) Coordinator revealed that R#94 had used the travel neck pillow for quite some time (over a year) at the daughter's request because she felt her mother was comfortable with its use. The MDS Coordinator confirmed that a care plan should have been developed to address the use of the resident's travel neck pillow. Cross Reference F688 | 2020-09-01 |