cms_GA: 1048
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1048 | MACON REHABILITATION AND HEALTHCARE | 115362 | 505 COLISEUM DRIVE | MACON | GA | 31217 | 2017-08-10 | 242 | D | 0 | 1 | 4CBP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident, and staff interview, the facility failed to ensure residents' rights to choose when they desired to get out of or go to bed was honored for two of 34 sampled residents. Residents (R#24 and R#91). Findings Include: 1. R#24 According to R#24's Clinical Resident Profile, R#24 was re-admitted to the facility on [DATE]. Review of the Medical [DIAGNOSES REDACTED]. Review of the most recent quarterly Minimal Data Set (MDS) (a standardize screening and assessment tool used for long term care residents), dated 7/7/2017, revealed under Section C - Cognitive Patterns that R#24 scored a 13 out of 15 on the Brief Interview for Mental Status (BIMS), indicating R#24 was cognitively intact. Section [NAME] - Behavior - E0800 documented that R#24 rejected care 1-3 days during the seven-day look back period. Section G - Functional Status - G0110 documented that R#24 required extensive assistance of two persons for transfers. During an interview, on 8/8/17 at 11:53 a.m., R#24 stated that staff put him to bed too early at night and get him up too late in the mornings. He discussed that, on his [MEDICAL TREATMENT] days, staff would wake him for breakfast at 7:30 a.m., but do not get him up out of bed until after 12:00 p.m. R#24 further shared, sometimes on the weekends staff don't get him up at all. Review of the R#24's care plan revealed there was no care plan initiated until 8/9/17 (during stage II investigations) which documented that R#24 .exhibited behaviors ie: does not want to get out of bed on [MEDICAL TREATMENT] days, verbally aggressive at times. The goal was that R#24 would cooperate with care through next review date. The interventions included; allow resident to make decisions about his treatments, educate resident and family regarding outcomes of non-compliance with care, give clear explanation of care activities prior to and as they occur, if resistive to care, reassure resident, leave and return to try again, maintain consistency in care for timing of care, comfort, and use consistent caregivers and routine as much as possible, provide resident with opportunities for choices during care and if possible negotiate a time with resident for care. Review of the Self-Care Deficit Care Plan, initiated on 12/19/16 and last update noted 8/10/17, revealed R#24 had a self-care deficit related to bilateral amputations, [MEDICAL CONDITION], and history of [MEDICAL CONDITIONS]. Resident will refuse to get OOB (out of bed) at times. On 8/10/17 the following intervention was added, Per resident preference ie: resident will tell staff when he wants to go to bed. Review of R#24's Progress Notes, dated 6/6/17 through 8/8/17, revealed there were two progress notes related to R#24's exhibiting behaviors related to wanting in or out of bed. A Progress Note, dated 7/20/17 at 10:39 p.m., documented Res (resident) was very hostile to staff (sic) screaming outside door and curing (sic) at staff .Asked res was he ready to go to bed he continued to hysterically scream at us and refused to go to bed. Asked again at 9:30 p, (sic) he did not want to go to bed. Once 10:45 pm (sic) came res was screaming again to be out (sic) in bed, while CNA was doing rounds. Was informed to use his call light, instead of screaming. (Sic) A second Progress Note dated 8/10/17 at 6:56 a.m., documented that R#24 had refused to get up that morning as he did not want to get up that early. During an interview, on 8/9/17 at 3:04 p.m., the MDS coordinator stated that it was brought up during R#24's care conference today that he will change his mind about going to bed or when he wants to get up on his [MEDICAL TREATMENT] days. During an observation and interview on 8/10/17 at 9:35 p.m., R#24 was noted to be lying in bed. R#24 stated that he had been waiting to get up as he was now ready to get up. During an observation on 8/10/17 at 11:10 a.m., the resident was noted to be lying in bed, the CNA staff had just cleaned him up and gotten him dressed. R#24 again verbalized that he wanted to get out of bed. 2. According to R#91's undated Admission Record R#91 was re-admitted to the facility on [DATE]. Review of the [DIAGNOSES REDACTED]. Review of the most recent quarterly MDS, dated [DATE], revealed under Section B0700- Makes Self Understood and B0800- Ability to Understand Others, R#91 was understood by others and able to comprehend others. Review of Section C - Cognitive Patterns indicated R#91 scored an 8 out of 15 on the BIMS, indicating R#91 had some moderate cognitive impairment. Section [NAME] - Behavior- E0800 documented that R#91 had no behaviors during the seven- day look back period. Section G - Functional Status- G0110 documented that R#91 required extensive assistance of one person for transfers. During an interview on 8/7/17 at 3:21 p.m., R#91 indicated staff leave him in bed all day and all night. During an additional interview with R#91, on 8/9/17 at 6:52 p.m., he stated a Hoyer lift (mechanical lift used for transfers) was used by staff to get him in and out of bed. He further indicated he usually only had one person assisting him with the transfer, unless he used the sit to stand lift (mechanical lift used for transfers then he had two staff persons assisting). R#91 revealed he usually waited an hour or longer to get help, because staff were busy. R#91 said, You just have to wait it out and eventually they will get to you. R#91 discussed that one day he did not get assistance at all, although he could not remember the date. During an observation and interview on 8/10/17 at 9:35 a.m., the Wound Care Nurse finished R#91's dressing change. She informed the resident staff would be in to get him dressed and out of bed, as she was not able to help get him up. Later, an observation and interview on 8/10/17 at 10:45 a.m., R#91 was observed lying in bed. R#91 was asked if staff had attempted to get him up, he stated no. On the same day at, 11:08 a.m. R#91 remained lying in bed. During an observation and interview on 8/10/17 at 11:20 a.m., with the Director of Nursing (DON) R#91 revealed he had wanted to get out of bed when he woke up this morning. He was reminded he had his dressing change and at the time the wound nurse had indicated staff would be in to get him up. R#91 was asked if he wanted to get up now and he replied, Yes, I have wanted to get up all day. The DON was informed that R#91 was told almost two hours ago that staff would be in to get him out of bed and yet he remained in bed. The DON informed the CNA staff to get R#91 up and acknowledged two hours was too long for him to be waiting. | 2020-09-01 |