cms_GA: 10403
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 |
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
10403 | ETOWAH LANDING | 115348 | 809 SOUTH BROAD ST | ROME | GA | 30161 | 2009-03-25 | 282 | K | 1 | 0 | 3LZE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident interview, and staff interview, the facility failed to ensure that three (3) residents ("A", #4 and #7) who had been assessed and care planned to receive thickened liquids, on the survey sample of nine (9) residents, received thickened liquids per their care plans. The failure of staff to ensure that these residents received thickened liquids represented the likelihood for serious harm for these residents. It was therefore determined that an immediate and serious threat to resident health and safety existed on March 25, 2009, and continues. Findings include: 1. Record review for Resident "A" revealed that the March 2009 physician's orders [REDACTED]. However, during an observation conducted on 03/25/2009 at 8:50 a.m., Resident "A" was observed to be seated in a wheelchair in his/her room by his/her bed. A cup containing unthickened water was sitting on an over-bed table directly in front of the resident within his/her reach, and a pitcher of unthickened water was sitting on the window sill, within the resident's reach. During an interview conducted at the time of the 03/25/2009, 8:50 a.m. observation referenced above, Resident "A" indicated that the unthickened water was his/hers. During an observation conducted on 03/25/2009 at 9:40 a.m., Certified Nursing Assistant (CNA) "CC" was observed providing the resident a pitcher containing unthickened water. Cross refer to F365, example 1, for more information regarding Resident "A". 2. Record review for Resident #7 revealed a March 2009 Dysphagia Initial Plan Of Treatment (Evaluation) which documented that the resident had a [DIAGNOSES REDACTED]. However, during observations conducted on 03/25/2009 at 08:51 a.m., 12:55 p.m., and 2:15 p.m., the resident was observed in the room in the bed, and a water pitcher containing unthickened water was observed on the cabinet located directly in front of the resident's bed. Cross refer to F365, example 2, for more information regarding Resident #7. 3. Record review for Resident #4 revealed that the resident's Interdisciplinary Care Plan contained a 03/14/2009 entry referencing the resident's nutritional risk, with Approaches which included the use of thickened liquids. However, the resident's March 2009 Nursing Assistant Care Card did not identify that the resident needed thickened liquids. During an interview conducted on 03/25/2009 at 1:30 p.m., Corporate Nurse "AA" stated that the facility's protocol was for CNAs to identify residents who were to receive thickened liquids by referencing resident Nursing Assistant Care Cards. Cross refer to F365, example #5, for more information regarding Resident #4. Based on the above, the facility failed to provide a functional system which ensured that residents who were care planned to receive thickened liquids received thickened liquids. This failure represented the likelihood for serious harm for these residents. | 2014-07-01 |