cms_GA: 1685
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1685 | WESTBURY CONYERS, LLC | 115469 | 1420 MILSTEAD ROAD | CONYERS | GA | 30012 | 2017-07-27 | 319 | D | 0 | 1 | DRP811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and clinical record review, the facility failed to provide psychological services to one resident (Resident (R) #118) of 29 sampled residents. R#118 had a [DIAGNOSES REDACTED]. The findings included: Review of the clinical record for R#118 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] revealed R#118 had a Brief Interview for Mental Status (BIMS) score of 13, which indicted intact cognition. The MDS recorded that R#118 had no mood or behavior symptoms, and received an anti-depressant for the seven days prior to the assessment. Review of the Care Area Assessment (CAA) for the admission MDS dated [DATE] revealed psychosocial well-being, mood state, and behavioral symptoms did not trigger for care plan development. Review of the care plan dated [DATE] revealed a problem identified with the use of anti-anxiety and anti-depressant medication. Interventions included monitoring for signs and symptoms of mood changes and depression, and symptoms of adverse side effects of the medication. Additional interventions included administering the medication as ordered and educating R#118 and family of the risk and benefits of the medication. Physician orders [REDACTED]. There were no medicines ordered for [MEDICAL CONDITION] or [MEDICAL CONDITION] disorder. The clinical record included a physician order [REDACTED]. There was no evidence in the clinical record of a psychological (psych) evaluation having been completed as ordered. Observation of R#118 on [DATE] at 3:52 p.m. in her room revealed her sitting on the side of the bed and she stated she did not want to talk because she was watching a movie. Observation of R#118 on [DATE] at 8:55 a.m. in her room revealed her to be lying in bed and she stated she did not want to talk because she was not feeling well and just wanted to see the nurse. Interview with Social Services (SS) DD on [DATE] at 3:15 p.m. at the nurse station revealed she could not find any documentation in R#118 clinical record that a psych evaluation had been completed. She also revealed the resident was not receiving any psych services. Observation of R#118 on [DATE] at 4:08 p.m. in the hall revealed her to be self-propelling a wheelchair towards her room. She stated she was getting supplies for her roommate but when she got back to her room it would be a good time to talk. Interview with R#118 in her room on [DATE] at 4:15 p.m. revealed she has lived in the facility for three months. She stated she was previously living in a homeless shelter after her fiance died . She further revealed that she was [MEDICAL CONDITION] and had not been able to afford her medications so she had gone without them for several weeks. As a result, she had a [MEDICAL CONDITION] and fell which is why she ended up in the facility. She stated her mood is going up and down and she really needs to be back on her medicine. R#118 stated, The doctor ordered a psych evaluation for me before giving me the medication but I haven't seen anyone yet. Interview with Licensed Practical Nurse (LPN) GG on [DATE] at 4:24 p.m. at the medication cart revealed R#118 is usually easy to get along with unless she wants medication. If she gets anxiety medication and pain medication at the same time, then she just sleeps. LPN GG stated she thought the doctor wanted to have a psych evaluation done but she was not aware if it had been completed. Interview with the Director of Nursing (DON) on [DATE] at 4:30 p.m. at the nurse station revealed R#118 does have a [DIAGNOSES REDACTED]. She stated that the facility would not necessarily have to get a psych evaluation and if she had been in the facility on [DATE], she would have left a note in the clinical record for the doctor to tell him she did not need a psych evaluation. Interview with Physician FF on [DATE] at 5:12 p.m. in the dietary office revealed he ordered a psych evaluation on R#118 because she was a new resident for him. He stated the history is sometimes difficult to obtain from residents but she had a [DIAGNOSES REDACTED]. He further stated he was not aware that the evaluation was not completed because he never received any recommendations. Interview with Registered Nurse (RN) EE Unit Manager on [DATE] at 10:08 a.m. at the nurse station revealed an order for [REDACTED]. RN EE stated, the order for the psych evaluation for R#118 dated [DATE] should have been called to the psych service utilized by the facility but, I don't know what happened. RN EE stated they usually work in conjunction with Social Services because they schedule the appointments. Interview with SS CC and SS DD on [DATE] at 10:47 a.m. in their office revealed the nursing staff will contact them when a consult is ordered and they make the referral. They both stated they were not made aware of the order in (MONTH) (YEAR) for a psych evaluation for R#118. Interview with Certified Nursing Assistant (CNA) BB on [DATE] at 10:59 a.m. in the hall revealed she has a good relationship with R#118. R#118 is usually happy and likes to help the other residents. Sometimes she stays in bed all day, which is rare for her, but she has pain and swelling in her legs. CNA BB stated, I usually tell the nurse when she does not want to get up. CNA BB revealed R#118 does not have any aggressive behaviors and she thinks R#118 likes living in the facility. Interview with the DON on [DATE] at 11:30 a.m. in her office revealed she does not have a written policy or procedure to verify that physician orders [REDACTED]. She further revealed that she was on vacation during the time in (MONTH) (YEAR) when the order for a psych evaluation for R#118 was missed. | 2020-09-01 |