cms_GA: 2
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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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 2 | A.G. RHODES HOME WESLEY WOODS | 115002 | 1819 CLIFTON ROAD, N.E. | ATLANTA | GA | 30329 | 2019-02-14 | 688 | D | 0 | 1 | PXEL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record reviews and review of the facility policy titled, Resident Mobility and Range of Motion the facility failed to assess and provide treatment for one Resident (R), (R#94) for neck positioning. The sample size was 26 residents. Findings include: Review of the facility's policy titled Resident Mobility and Range of Motion reviewed on 2/1/18 revealed 3. Residents with limited range of motion will receive treatment and services to increase and/or prevent further decrease in range of motion; 4. Residents with limited mobility will receive appropriate services, equipment and assistance to maintain or improve mobility unless reduction in mobility is unavoidable .5. Therapy will evaluate/reevaluate the resident's mobility on a routine basis to determine the need for range of motion exercises. Review of the clinical record for R#94 revealed an Annual Minimum Data Set (MDS) assessment dated [DATE] with documented [DIAGNOSES REDACTED]. Continued review of the MDS revealed R#94 was severely cognitively impaired and exhibited no behaviors during the assessment period. The resident required extensive to total assistance of one to two staff persons for all Activities of Daily Living (ADLs). During this assessment period, R#94 received Occupational Therapy (OT), passive range of motion (ROM), and splint/brace assistance. Review of the Task tab for R#94 printed from the electronic record on 1/31/19 revealed the resident required total assistance for eating; required two-person total dependence for bathing, bed mobility, and dressing. These tasks were to be completed by the Certified Nursing Assistants (CNAs). Further review revealed Restorative staff was to provide the resident with passive ROM to the left hand six times per week for 15 minutes for each treatment and was to apply a splint/brace to her left hand for up to six hours - six times per week. The Task tab did not list the use of a travel neck pillow to be used for proper head positioning. Review of the comprehensive care plans for R#94 last reviewed on 1/12/19 revealed the plan did not list appropriate head positioning as a focus area requiring interventions. Review of Therapy Screening Forms for R#94 dated 4/26/18, 7/31/18, 9/25/18 and 12/17/18 revealed a section with instructions to Indicate all areas reflecting a change in condition or an area with a deficit that may warrant therapy. For each screening form, the items in this section were left blank and unaddressed. Some of the items included in this section were: Poor positioning/body alignment, swallowing difficulties, choking/coughing with meals/meds. The 12/17/18 screening form recommended an OT evaluation. Review of the OT Discharge Summary for R#94 dated 1/11/19 revealed R#94 received OT services from 12/18/18 through 1/11/19. R#94 received OT services for the following reasons: 1) increase trunk strength; 2) increase sitting balance during ADLs; 3) to achieve normal anatomical alignment of the right hand for three hours using a hand roll; 4) to exhibit a decrease in pain at rest in the left hand to improve functional use of upper extremities during ADLs; and 5) to safely wear finger extension splint on left fingers for up to five hours. R#94 was discharged from OT services on 1/11/19 due to achieving the highest practical level of functioning. One of the discharge recommendations was to continue to use cervical travel pillow when in bed and in Broda chair. Review of an Interdisciplinary Communication Memo for R#94 dated 1/11/19 completed by OT BB documented the following: to Continue to use cervical travel pillow when in bed and Broda chair to maintain appropriate head positioning. Observation in the resident's room on 1/28/19 at 10:55 a.m. revealed R#94 was lying in her bed with the head of the bed (HOB) elevated approximately 30 degrees. R#94 had a travel neck pillow around the back of her neck and the resident's head was bent forward and to the right near her shoulder with the resident's chin touching her chest as she slept. Observation in the resident's room on 1/30/19 at 11:35 a.m. revealed R#94 was lying in her bed and positioned slightly on her right side. The resident had the travel neck pillow around her neck, and her chin rested on her chest near her right shoulder. Interview at the nurses' station on 1/30/19 at 12:06 p.m. with Registered Nurse Charge Nurse (CN) AA revealed that R#94 used the travel neck pillow for positioning and for comfort. Registered Nurse CN AA confirmed, at this time, that the resident's head alignment was chin-to-chest, and stated that it had been that way for at least several months. Observation in the day room of the secured unit on 1/30/19 at 2:35 p.m. with OT BB present revealed R#94 was sitting in a padded Broda chair with her travel neck pillow behind her neck. The resident's chin was resting on her chest and leaning towards her right shoulder. During an interview at this time with OT BB in the day room of the secured unit, the therapist confirmed R#94 did not have appropriate neck positioning. OT BB revealed the travel neck pillow was something the family wanted the resident to have to address the resident's right lateral lean of her head towards her right shoulder that began over a year ago. OT BB stated that it was possible the travel neck pillow was contributing to the resident's chin sitting on her chest and therefore, OT BB felt she needed to screen the resident regarding neck flexion and the possible use of a neck collar. Interview on 1/30/19 at 3:50 p.m. with the Director of Nursing (DON) and MDS Coordinator revealed R#94's daughter encouraged and provided the use of the travel neck pillow. The DON said the pillow was brought in by the daughter over a year ago because the daughter felt her mother was comfortable with its use. Observation of R#94 in the day room of the secured unit with the DON present on 1/30/19 at 4:10 p.m. revealed the resident had the travel neck pillow around her neck and the resident's chin was resting on her chest. During an interview at this time in the day room of the secured unit with the DON, the DON stated she had not seen the resident's head/neck in that position before and felt that it (chin-to-chest position) was something that had recently happened. Interview on 1/31/19 at 8:55 a.m. with the DON revealed the DON had spoken with OT BB and that the therapist informed her that the intended purpose was for the travel neck pillow to be used as a preventative intervention for hyper-extension of the resident's neck (going backwards) but after looking again, the OT BB felt the travel neck pillow may be causing flexion of the neck muscle (going forward). Interview on 1/31/19 at 10:38 a.m. with the DON revealed OT BB assessed R#94 (on the morning of 1/31/19), and OT BB was going to call the residents daughter to discuss discontinuing the use of the travel neck pillow. Follow-up interview with the DON on 1/31/19 at 11:46 a.m. revealed that the DON spoke with the resident's daughter and that the daughter explained that the initial reason for getting the travel neck pillow was to keep the resident's head from leaning to the right side. She said the daughter realized that the resident's head was now moving forward in the chin-to-chest position and the daughter agreed with discontinuing the use of the travel neck pillow. Interview on 1/31/19 at 12:46 p.m. with OT BB revealed the therapist completed the resident's screening and the resident was going to be picked up for therapy to do some neck exercises and stretching and to determine if a soft collar should be utilized. OT BB said the daughter was in agreement of discontinuing the use of the travel neck pillow. Follow-up interview on 1/31/19 at 2:05 p.m. with OT BB revealed when asked about the resident's quarterly therapy screens not addressing the resident's neck posture, OT BB said that when she evaluated the resident earlier in (MONTH) 2019, she looked at her mostly for her hand splint. OT BB said she didn't realize until today (1/31/19) how thick and heavy the travel neck pillow was and said, gravity and the pillow are causing it (the resident's neck) to move forward and thrust her chin against her chest. The therapist stated the travel neck pillow needs to be discontinued. | 2020-09-01 |