cms_GA: 2188
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 |
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
2188 | RENAISSANCE CENTER FOR NURSING AND HEALING | 115537 | 415 AIRPORT ROAD | GRIFFIN | GA | 30223 | 2016-12-08 | 514 | D | 0 | 1 | 02KJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interviews and review of facility policy, NSG253 [MEDICAL TREATMENT] Communication and Documentation the facility failed to maintain complete [MEDICAL TREATMENT] communication forms for one (1) resident (R#107) of twenty-seven (27) sample residents. Findings Include: Resident (R#107) was admitted to the facility on [DATE] with a primary [DIAGNOSES REDACTED]. Record review of the [MEDICAL TREATMENT] Communication Record forms for the months of October, and (MONTH) (YEAR) revealed missing forms for 10/1/16, 10/4/16, 10/13/16, 11/1/16, 11/17/16 and 11/22/16. Review of the facility policy titled NSG253 [MEDICAL TREATMENT] Communication and Documentation dated 5/1/16 indicated center staff will communicate with the [MEDICAL TREATMENT] center prior to sending a patient for [MEDICAL TREATMENT] by completing the [MEDICAL TREATMENT] Communication Record or other state required form and sending it with the patient. The form will also be completed upon return of the patient from the [MEDICAL TREATMENT] center. The policy also indicated upon return of the patient to the Center, a licensed nurse will review the [MEDICAL TREATMENT] center communication; evaluate/observe the patient; document the evaluation/observation on the [MEDICAL TREATMENT] Communication Record or state required form, notify the [MEDICAL TREATMENT] center if the form is not returned with the patient and ask that it be faxed to the center; document notification of [MEDICAL TREATMENT] center regarding return of form or other communication; maintain the [MEDICAL TREATMENT] Communication Record or state required form in the patient's medical record. During an interview with the Director of Nursing (DON) on 12/8/16 at 5:00p.m. she stated she expects the nursing staff to document in the nurses notes all [MEDICAL TREATMENT] communication information received on the [MEDICAL TREATMENT] Communication Record form or if no change in condition/other pertinent information is written for the nurse to document in the progress notes the evaluation of the resident when he returns to the facility. The DON confirmed there are missing and incomplete [MEDICAL TREATMENT] Communication Record forms for the months of (MONTH) (YEAR) and (MONTH) (YEAR) and that there are no progress notes regarding the evaluation of the resident after returning from [MEDICAL TREATMENT] for days in (MONTH) and (MONTH) of (YEAR). She confirmed there is no section on the MAR for October, (MONTH) or (MONTH) to monitor bruit and thrill. | 2020-09-01 |