cms_GA: 1053

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.

Data source: Big Local News · About: big-local-datasette

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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
1053 MACON REHABILITATION AND HEALTHCARE 115362 505 COLISEUM DRIVE MACON GA 31217 2017-08-10 318 D 0 1 4CBP11 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and clinical record review, the facility failed to ensure one resident (R#48) of 34 sampled residents reviewed had a splint placed on the right hand to prevent further contracture and ensure the splint was appropriate for the resident's needs. Findings include: Review of the Face Sheet, R#48 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the most recent quarterly Minimum Date Set (MDS) (a standardize screening and assessment tool used for long term care residents) dated 6/15/2017 revealed a Brief Interview for Mental Status (BIMS) of four out of a score of 15 indicating severe cognitive impairment. Section G - Functional Status - Dressing and Personal hygiene Resident required extensive assistance of one person. The Care Plan initiated on 12/23/2016 identified a focus of self-care deficit related [MEDICAL CONDITION] right hand [MEDICAL CONDITION], hand contracture. Goals with a target date of 9/22/2017 indicated the resident will have ADL (activities of daily living) needs met. Splint right hand as tolerated/per order was listed as an intervention. Review of the current (MONTH) Physician Orders, revealed an order for [REDACTED]. Staff interview on 8/8/2017 at 11:23 a.m., with Licensed Practical Nurse (LPN) JJ revealed R#48 does have a contracture of the right arm. When asked if the resident receives range of motion (ROM) or have a splint device in place LPN JJ stated no. Observations of R#48 on 8/9/2017 at 3:13 p.m., and on 8/10/2017 at 9:04 a.m., revealed the resident did not have a splint on the right hand. Interview on 8/10/2017 at 10:07 a.m., with the Assistant Director of Nursing (ADON) who was responsible for overseeing the restorative nursing program revealed R#48 participated in the restorative nursing program. She further revealed R#48 ambulated with a hemi-walker, and was motivated. When asked about the right-hand splint the ADON indicated she would need to check with the restorative aide, but thinks she remembers seeing a blue splint. Observation of R#48's room and interview with Restorative Certified Nursing Assistant (RCNA) HH and the ADON on 8/10/2017 at 10:20 a.m., revealed no splint was located in the resident's room. RCNA HH stated, R#48 use to have a splint, but she had a fit about using it, I think it was DC'd (discontinued) a while back, not sure when. The ADON stated if the splint is on the current Physician order [REDACTED]. Review of the Restorative Nursing Care Flow Record from (MONTH) (YEAR) to current date revealed the restorative program of ambulation with the goal of proper positioning of right ankle in the wheelchair leg rest and gait exercises with a hemi-walker. There was no documentation related to the use of the right-hand splint, nor was there any documentation of the resident's refusal to use the splint or of the resident not being able to tolerate the use of the hand splint. Interview with the Certified Occupational Therapy Assistant (COTA) on 8/10/2017 at 10:58 a.m., revealed she was familiar with R#48. The COTA indicated the ADON asked her about R#48's hand splint. The COTA further indicated she did not know if or when the splint may have been discontinued. The COTA stated, I gave her (the ADON) a palm protector to try. At 11:05 a.m., the ADON showed the surveyor a sheepskin palm protector. Observation of R#48 on 8/10/2017 at 11:10 a.m., revealed R#48 rolling self in wheelchair from an activity with a rolled wash cloth in the right hand. 2020-09-01