cms_GA: 1114
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1114 | RIVERSIDE HEALTH CARE CENTER | 115375 | 5100 WEST ST NW | COVINGTON | GA | 30014 | 2020-02-13 | 688 | D | 0 | 1 | W93S11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review, the facility failed to provide rehabilitation equipment in a timely manner to one resident, Resident (R) #96 of 43 sampled residents. Findings include: An interview and observation on 2/10/2020 at 11:19 a.m. with R#96 revealed that she has received therapy quite a few times during her time there. She further indicated her neck has started drawing to her right shoulder and has informed her Physician and therapy is aware. The resident was observed with her head drawing to the right shoulder. Additionally, she reported a neck pillow had been ordered twice, but she has not yet received it. A review of R#96's [DIAGNOSES REDACTED]. Additionally, R#96 underwent neck surgery in (MONTH) 2019. A review of the Annual Minimum Data Set (MDS) assessment dated [DATE] revealed the following triggered care areas: Activities of Daily Living (ADL) functional/rehab potential, and pain. It further revealed R#96 scored 15 on the Brief Interview for Mental Status (BIMS). A review of the Quarterly MDS assessment dated [DATE] revealed resident requires extensive assistance with transfers, dressing, and toileting, with set up with bathing, and has functional limitation in range of motion (ROM) on one side of her upper extremity. A review of R#96's care plan revealed the following problem areas: 1. Right shoulder contracture and has a problem with her left shoulder rotator cuff. Goal is for the resident to minimize further contraction through next review date. Interventions include; support affected area, keep affected area clean, monitor skin breakdown, assist with ROM as needed, reinforce activities recommended, encourage participation in selfcare as allowed, perform actions to maintain an adequate nutritional status. 2. limited physical mobility related to (r/t) Weakness. Goal is that the resident will demonstrate the appropriate use of adaptive device(s) to increase mobility through the review date. Device: Right ASSIST BAR; Left: none. Intervention: MOBILITY: uses assistive device/enabler for bed mobility and transfers. A review of the Occupational Therapy (OT) Evaluation and Plan of Treatment note dated 8/31/19 revealed under Additional Abilities/Underlying Impairments: Tone and Posture; Posture = Head Forward. Evaluation Summary Components, Physical/Cognitive/Psychosocial Performance: impaired activity tolerance, functional strength, sitting tolerance and pain to surgical site and both shoulders. Self-care assessment score was 25 out of 48. There is no evidence in the evaluation of functional measurements for neck mobility of the resident post neck surgery. A review of OT Treatment Encounter Notes from 8/31/19 to 10/18/19 revealed instructions on cervical precautions for her neck was provided on 9/10/19 and 9/12/19; then on 9/27/19 Activities for midline neck alignment, patient demonstrates increased positioning and ROM; on 9/30/19 patient requires cues for neck positioning tends to position lateral to right, activities for midline; cervical precautions were then instructed on 10/1/19, 10/2/19, and 10/9/19. A review of the OT Discharge Summary dated 10/18/19 revealed her self-care assessment score to be 30 out of 48. There is no evidence of functional measurements for neck mobility for the resident post therapy. An interview on 2/13/2020 at 10:05 a.m. with Certified Occupational Therapy Assistant (COTA) FF, she reported they have seen R#96 multiple times, with the most recent treatment episode following her neck surgery in (MONTH) 2019. She reported the resident had sensory impairment related to the nerve damage in her neck and they worked on ROM for her neck. COTA FF reported after the resident's neck surgery, her neck began drawing to the right and requested an order for [REDACTED]. She indicated this item had not arrived for the resident to date. An interview on 2/13/2020 at 10:25 a.m. with the Director of Rehabilation (DOR) she indicated once she receives an Equipment Request, she sends it to Central Supply and they order the product. She indicated she sent this request to central supply on 10/15/19 and 11/4/19 to Certified Nursing Assistant (CNA) GG in central supply. The DOR indicated she follows up with central supply when ordered items are not received. DOR confirmed the resident had not received the foam cervical collar to date. An interview on 2/13/2020 at 10:49 a.m. with CNA GG revealed that she had placed orders for the sleep right neck pillow prior to 10/15/19. A review of the email string between CNA GG and the DOR, revealed a follow up was requested on 10/15/19. CNA GG replied she had ordered the item but would inquire about it. CNA GG revealed contacting the vendor representative on 10/22/19 who stated the collars were ordered on [DATE] and delivered on 9/9/19. CNA GG confirmed the foam cervical collars had not been received and inquired if the DOR wanted to re-order the items. There is no evidence of the DOR responding to this request in the medical record. A review of the email string revealed no response from the DOR. On 2/13/2020 at 11:06 a.m. CNA GG contacted their vendor representative who confirmed three foam cervical collars were ordered on [DATE] and shipped next day air and delivered on 9/9/19. At this time, CNA GG reordered the cervical collars via phone, and confirmed their method for following up on undelivered items includes a call to the company the item is ordered from. An interview on 2/13/2020 at 2:55 p.m. with the Administrator revealed that she was not aware of the missing collar. She indicated their process for ordering therapy items, is for therapy to notify central supply who places the order. Once the order is received, someone signs for delivery and the appropriate department is notified to pick it up. The Administrator agreed if it was delivered in September, they needed to track where it was. She further indicated the foam cervical collar is not an item that would require a physician's orders [REDACTED]. In an interview on 2/13/2020 at 7:28 p.m. with the DOR revealed that she is responsible for ensuring equipment arrives for a resident including following up on items ordered by the rehab department that have not been delivered. Additionally, the DOR screened the resident on 2/13/2020 at 7:45 p.m. for potential neck contracture and determined the following; Patient head noted in resting position in lateral flexion to right side. Patient able to correct self to mid line. No contracture noted. | 2020-09-01 |