cms_GA: 2516
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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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 2516 | FULTON CENTER FOR REHABILITATION LLC | 115569 | 2850 SPRINGDALE ROAD SW | ATLANTA | GA | 30315 | 2018-09-27 | 684 | E | 1 | 1 | KB6111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, clinical record review, observations, and staff interviews, the facility failed to ensure three (R#14, R#74, and R#197) received appropriate services to ensure their highest practicable physical well-being. Specifically, R#14 was not treated in a timely manner for a broken leg, R#74 did not receive timely treatment for [REDACTED].#197 was not assessed prior to being moved after a fall. The findings include: 1. The facility's policies related to a resident change of condition were requested from the Director of Nursing (DON) on 9/27/18 at approximately 2:30 p.m. The DON stated that she was not able to locate any such policies. R#14 was admitted to the facility on [DATE] with diagnoses, according to the Admission Record dated 9/26/18, including heart failure and hypertension. A Risk Management System Report, dated 8/29/18 noted, Resident stated that another resident accidentally hit her left foot with a power chair at 200-hall nurses' station. Resident verbalized pain to left extremity. Warm to touch. Color consistent to ethnicity. Resident assisted to bed. Minimal movement to left leg. The report indicated the resident's physician was notified of the incident. The Minimum Data Set (MDS), a quarterly assessment of overall health status, dated 6/23/18, indicated R#14 was cognitively intact (the Brief Interview for Mental Status (BIMS) test score was 15/15), and the resident was totally dependent upon one to two staff members to complete most of her Activities of Daily Living (ADLs), including transfers. The assessment indicated the resident was independent with ambulation after being transferred to her power wheelchair. In addition, the assessment indicated the resident had limited range of motion to her upper and lower extremities on one side of her body. The ADL (Activates of Daily Living) Care Plan, dated 9/14/18, read: Focus: Resident requires assistance for ADLs; and Goal: Resident's ADL care needs will be anticipated and met through next review. Interventions included: Monitor for complications of immobility. No care plan could be found in the resident's record to indicate an injury to the resident's left foot. The Order Recap Report, dated 8/29/18 - 8/30/18 was reviewed and indicated an order for [REDACTED]. An X-Ray Report, dated 8/30/18 read: Reason for Study: Pain in left foot. Results: There is a displaced [MEDICAL CONDITION] tibial shaft. Conclusion: Acute displaced fracture of distal tibial shaft. The Order Recap Report, dated 8/29/18 - 8/30/18 was reviewed and indicated an order for [REDACTED]. physician's orders [REDACTED]. physician's orders [REDACTED]. physician's orders [REDACTED].>The Medication Administration Record [REDACTED]. On 9/15/18, the [MEDICATION NAME] order returned to the original 220 mg twice daily as needed The MAR indicated [REDACTED]. The record indicated R#14 received the Tylenol on 9/2/18 for a pain level of 4/10, on 9/3/18 for a pain level of 4/10, on 9/5/18 for a pain level of 4/10, and on 9/7/18 for a pain level of 3/10. A Change of Condition Note, dated 8/29/18 at 8:33 p.m., Note: A change in condition has been noted. The symptoms include: Other change in condition (left foot pain) on 8/29/2018 in the afternoon. Change reported to Primary Care Clinician on 8/29/2018 at 7:00 p.m. Orders obtained include: x-ray to left foot. Medicate for pain PRN (as needed) and as ordered. Continue to monitor. MD (Medical Doctor) will come see the resident. Caution while moving left lower extremity. A Nurses Note, dated 8/29/18 at 10:00 p.m. revealed R#14, Sustained left foot injury after another resident accidentally hit her with power chair. MD notified. New order for x-ray obtained. A physician progress notes [REDACTED]. History of Present Illness: [AGE] year-old female who is reporting pain to the left foot which she reports that it started yesterday after an incident involving another patient with a motorized wheelchair. X-ray of the left LE (lower extremity) shows displaced [MEDICAL CONDITION] tibial shaft. No [MEDICAL CONDITION] or toe. Patient reports effective results with current pain management, instructed patient to notify nursing staff if current plan is no longer effective. Patient's history is also significant for Vit (Vitamin) D deficiency which may make her more prone to fractures. Diagnosis, Assessment and Plan: Pain of left lower extremity. Will order ortho consult following x-ray results showing displaced [MEDICAL CONDITION] tibial shaft. Continue [MEDICATION NAME] and Tylenol as ordered for pain. A Nurses Note, dated 8/30/2018 at 8:15 a.m. read, x-ray to left foot done, resident tolerated well, denies pain or discomfort. Will continue to monitor. A Nurses Note, dated 8/30/18 at 10:30 a.m. read, This is a follow-up note from the change in condition-medical that occurred on 8/30/2018. Resident complained of pain to left foot. NP (Nurse Practitioner) in and copy of X-ray viewed and results indicate a fracture of distal tibial shaft. A Nurses Note, dated 9/1/18 at 12:30 p.m. read This is a follow-up note from the change in condition-medical that occurred on 08/29/2018. Resident given [MEDICATION NAME] 220 mg (milligrams) for pain. No further complaints voiced. A Nurses Note, dated 9/2/18 at 12:30 p.m. read, This is a follow-up note from the change in condition-medical that occurred on 08/29/2018. Resident alert and in no acute distress. Medicated with Tylenol 650Mg and [MEDICATION NAME] 220 mg for pain with effective results. A Nurses Note, dated 9/2/18 at 2:30 p.m. read, , Resident received [MEDICATION NAME] 220 mg and Tylenol 325 mg 2 tablets for pain with effective results. A Nurses Note, dated 9/2/18 at 10:30 p.m. read, , Resident continues to receive [MEDICATION NAME] for pain as needed. A Physician's Progress Note, dated 9/4/18 at 12:00 a.m., Chief Complaint / Nature of Presenting Problem: Left foot pain- patient is requesting some ice for her leg. History of Present Illness: [AGE] year-old female (resident) lying in bed and in no acute distress. Charge nurse reports that (resident) is requesting some ice for her left leg and that patient's niece wanted a second opinion in regards to LLE (left lower extremity) fracture/ displaced [MEDICAL CONDITION] tibial shaft. Discussed scheduling [MEDICATION NAME] for 7 days and then going back to previous schedule. Educated (resident) that ice is usually effective within the first 24-48 hours after an injury. Also reminded patient of the referral for orthopedics. Will schedule [MEDICATION NAME] Q (every) 12 HRS (hours) X7 days and then return to PRN (as needed) schedule, follow up with ortho a previously ordered for displaced [MEDICAL CONDITION] tibial shaft. Pain medication as ordered. No Progress notes could be found in the clinical record to address the resident's leg fracture between 9/4/18 and 9/25/18. A Nurses Note, dated 9/25/2018 at 11:19 a.m. read, , Late Entry: Resident went to the scheduled appointment for orthopedic consult via stretcher transport. Resident was not seen at the appointment: Orthopedist needed the transport to stay with the resident until she could be seen. Consequently, the resident was not seen. Grady was contacted for an appointment to follow up using stretcher transportation. Awaiting an appointment with Grady for orthopedic follow up. Niece is notified. A Nurses Note, dated 9/25/2018 at 12:00 p.m. read, , Late Entry: Note: (R#14) had a planned transfer. planned testing. A Nurses Note, dated 9/25/2018 at 2:56 p.m., Resident is transported to (Hospital) emergency room for orthopedic consult via stretcher (Ambulance Service) at approximately 1:45 p.m. Awaiting return and follow up orders. A Nurses Note, dated 9/26/2018 at 7:42 a.m. read, , Resident is admitted to Hospital unit 6[NAME] Per nursing report closed reduction and splinting was done. Call placed to niece and message left regarding resident's admission to the hospital. No Nursing Assessments could be found related to the resident's broken left lower extremity in the clinical record. During an interview with the Director of Nursing (DON) in her office on 9/26/18 at 10:51 a.m., she stated, (R#14) was not seen by the orthopedic physician due to someone could not stay with her on stretcher. The original appointment was on the 13th. Medical Records Manager (BB) makes all of the appointments. The DON indicated she did not know why it had taken so long to get R#14 in to see an orthopedic physician after her leg was broken. During an interview with Unit Manager (UM) AA in the conference room on 9/26/18 at 10:58 a.m., she stated, We had sent her out for an ortho consult prior to now. She has to go via stretcher, so when she got to the appointment the transport company could not stay with her and they refused to leave their stretcher at the office, so we tried to get her another appointment at (the Hospital) to be seen. No other office would accommodate her. We called the (Hospital) initially a day or so ago. We were trying to find out when an ortho (orthopedic physician) was going to be in the ER (emergency room ) to see her. We finally were able to coordinate an ortho in the ER last night. We've been trying to address the situation. She had a distal tibial fracture. She continued to have pain so the Nurse Practitioner (NP) ordered her pain meds, and nothing was resolved. During an interview with Medical Records Director (MRD) BB in the conference room on 9/26/18 at 11:04 a.m., she stated, R#14 originally went to an orthopedic clinic on 9/13/18, but the clinic would not see the resident because she arrived there on a stretcher. On 9/14/18, the hospital said they would take her via stretcher as long as there was an order for [REDACTED].#14 was sent to the ER (emergency room ) to be seen for her injured foot. During an interview with R#14 after her return from the hospital in her room on 9/27/18 at 12:18 p.m., she stated, I have a splint all the way up to my knee now. They put it on me at the hospital. That doctor over there asked me 'Why are they just sending you over here now if this break happened almost a month ago?' He said that to me. I told him I don't know. That's a good question. I had pain in my leg the whole time after the break. It's better now that it's splinted. The resident's left lower leg was observed to have a splint in place. During an interview with the Nurse Practitioner (NP) on 9/27/18 at 12:45 p.m., she stated she was aware of the resident's broken leg. She said she found out when reading the 24- hour report when it first occurred and the nurse told her the injury involved the resident's leg. The NP said she ordered x-rays. The NP further stated the following: At first, we increased her [MEDICATION NAME] to a scheduled dose .220mg twice a day for 7 days. She was taking it as needed before that. The same week the nurse told me that she was requesting some ice for the leg. I saw her again and told her ice doesn't really treat fracture after the firs 24 to 48 hours. They (nursing) told me they were scheduling the orthopedic appointment. She was not in distress at that time. (That day) I increased the [MEDICATION NAME] to 550 MG every 12 hours for the next 7 days. I also asked her if I could order her some [MEDICATION NAME] and she said no. She doesn't want to take strong medication. She (R#14) doesn't like narcotics. I do understand the concern about the delay in her appointment. If a patient isn't seen as scheduled, they (nursing) should communicate to me and they did not. I didn't find out that she hadn't been seen (by an orthopedic doctor) until Monday (9/24/18). I thought she had been seen. If I had known she had not been seen as scheduled I would have been able to evaluate the situation and said, (R#14) do you want to go out to the hospital? Do you want more pain medicine? Etc. They (nursing staff) put me a difficult situation. If they don't tell me what is going on, I don't know. I saw her today and they put the splint on her at the hospital. She says she's comfortable now. 2. The facility's Skin Integrity Management Policy, dated 11/28/16, read, The implementation of an individual (patient's skin integrity management occurs within the care delivery process. Staff continually observed and monitors patients for changes and implements revisions to the plan of care as needed; and Purpose: to provide safe and effective care to prevent the occurrence of pressure ulcers, manage treatment, and promote healing of all wounds; and Implement skin/wound care guidelines as applicable. R#74 was admitted to the facility on [DATE] with diagnoses, according to the Admission Record dated 9/26/18, including [MEDICAL CONDITION]'s Disease and movement disorder. The Minimum Data Set (MDS), a quarterly assessment of overall health status, dated 8/18/18, indicated R#74 was severely cognitively impaired (the Brief Interview for Mental Status (BIMS) test could not be done due to the resident's severe cognitive impairment) and the resident was dependent upon one to two staff members to complete all of his Activities of Daily Living (ALs). In addition, the assessment indicated the resident did not have any pressure or non-pressure wounds on his body at the time of the assessment. The Skin Care Plan, dated 9/21/17, read, , Focus: Resident is at risk for skin breakdown r/t (related to) cognitive deficits, uncontrollable movements due to [MEDICAL CONDITION]'s Disease; and Goal: The resident will not show signs of skin breakdown through next review. Interventions included, apply barrier cream with each cleansing, assess/remind the resident to reposition as needed, observe skin condition with ADL care daily and report abnormalities, and weekly skin assessment by licensed nurse. The most recent Braden Scale for Predicting Pressure Sore Risk, dated 5/4/18, revealed a score of 12, indicating R#74 was at high risk for developing pressure sores. The Medication Review Report, dated 9/18, indicated no current orders for wound care. The Medication/Treatment Administration Records, dated 9/18 were reviewed and indicated no treatments were being received for wound care or skin maintenance. Skin Check Records for R#74, completed by the licensed nurse and dated 8/7/18, 8/10/18, 8/17/18, 8/24/18, 8/31/18, 9/7/18, 9/14/18, and 9/21/18 were reviewed and indicated no skin injuries or pressure areas were present on the resident's body. ADL Records, dated 6/18 through 9/18 were reviewed, and indicated R#74 was receiving baths/showers at least twice weekly as scheduled. Only one Bath Record Skin Audit was found for the reviewed date range of 6/1/18 through 9/26/18. The skin audit was dated 6/19/18, ad indicated the resident had an open area to his right lower extremity at the time of the audit. The nurse signature and date section on the audit was blank. R#74 was observed, lying in his bed on 9/24/18 at 10:43 a.m. An open area to the resident's right shin under his knee was observed. The open area was round and appeared to be approximately the size of a quarter. A second circular open area was observed below the first open area and appeared to be approximately 0.5 centimeters around. R#74 was observed, lying in his bed on 9/25/18 9:44 a.m. The open areas on the resident's lower right extremity remained as observed above. R#74 was observed lying in his bed on 9/26/18 at 8:19 a.m. The open areas on the resident's right lower extremity remained as observed above. During an interview with Certified Nursing Assistant (CNA) EE in the resident's room on 9/26/18 at 8:30 a.m., he stated, I personally don't document the skin stuff. (R#74) has involuntary movements. He can't control his movements and he bumps into things. We use ointment and barrier cream on his skin. CNA EE indicated he had not noticed the open areas on R#74's lower right extremity. During an interview with (CNA) DD on the 200 Hallway on 9/26/18 at 9:19 a.m., she stated she worked with R#74 on a full-time basis, and she stated, The last skin issue I reported (for R#74) was when he hit his shin on the geri-chair and broke it (the chair) last month. CNA DD said she hadn't noticed any other skin issues for R#74 and said she. reports to the nurse when I see something. During an interview with Licensed Practical Nurse (LPN) GG on 9/26/18 at 8:32 a.m., she stated, He (R#74) doesn't have any skin treatments. There is nothing on the Treatment Record. The surveyor observed R#74's skin with LPN GG, and she stated, (R#74) just gets A and D Ointment. He doesn't have any treatment orders. He kicked the hinges off his geri-chair last week. That's what happened (to his right lower extremity). During an interview with the Director of Nursing (DON) on 9/26/18 at 8:38 a.m., she stated, As far as I know (R#74) just has abrasion on his knee. It looks to be healed (according to the documentation in the record). I don't see any other open areas (in the documentation in the record). During an observation conducted with the DON present, R#74 was observed lying in his bed, on 9/26/18 at 8:39 a.m. The DON stated, the open areas on the resident's right lower extremity look like they are re-opened areas. I'll get with the nurse. Triple antibiotic should be on there. The last time I saw (the area) it was scabbed. It's re-opened. The DON said the CNAs and nurses look at residents' skin and report any findings. During an interview with Unit Manager (UM) AA in the nurse's station on 09/26/18 at 8:42 a.m., she stated, I was not told of (R#74's) re-opened area (on his right lower extremity). I should have been told. During an interview with UM AA in the Nurse's Station on 9/26/18 at 08:44 a.m., she indicated she was unable to find bath skin records for R#74 in the bath book (other than the bath skin sheet dated 6/19/18 referred to above). She stated, R#74 should be getting baths twice per week at a minimum, and a bath skin sheet should be done with each bath. The CNA's are supposed to give the bath skin sheet to me so that I can track any skin concerns. UM AA acknowledged that this had not happened for R#74 with regards to the open area on his right lower extremity. 3. Review of R#197's clinical record revealed the resident was admitted into the facility on [DATE] with admitting [DIAGNOSES REDACTED]. Review of R#197's Admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident scored 0 out of 15 on the Brief Interview for Mental Status (BIMS) indicating the resident was severely cognitively impaired. According to the MDS, R#197 was independent with bed mobility, transfers, walking in the room/corridor, locomotion on the unit, toileting and hygiene. R#197 was steady at all times when moving from seated to standing position, moving on and off the toilet, and surface-to-surface transfers. R#197 was not steady but able to stabilize without the assistance of staff when walking (with assistive device if used) and when turning around and facing the opposite direction while walking. The resident had no impairment of upper and lower extremities and utilized a walker for mobility. The resident had at least one (1) fall within the prior 2-6 months prior to admission. The fall(s) did not result in a fracture. Review of R#197's care plan dated 6/12/18) revealed the following: Focus: Resident is dependent for ADL (activities of daily living) care in: bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, toileting related to: Chronic disease. Interventions: Monitor for decline in ADL function. Refer to rehabilitation therapy if decline in ADLs is noted; Monitor for pain. Attempt non-pharmacological interventions to alleviate pain and document effectiveness. Administer pain medication as ordered and document effectiveness/side effects; Monitor laboratory test results and report abnormal results to physician/mid-level practitioner; Monitor for complications of immobility; provide cueing for safety and sequencing to maximize current level of function. Redirect resident to ambulate with walker; assist resident getting in and out of bed; and assist resident with ambulation. Focus: Resident is at risk for falls; unsteady mobility. Interventions: place call light within reach while in bed, or in close proximity to the bed; Maintain a clutter-free environment in the resident's room and consistent furniture arrangement. Review of the Risk Management System report dated 7/3/18 revealed R#197 had an unwitnessed fall. LPN took the resident's vital signs post fall at 3:15 p.m. (Temperature - 98.6 degrees, Pulse - 91, Respirations - 20 and Blood pressure 151/74). The report noted the resident was transported to the hospital via ambulance at 10:30 p.m. The circumstances of the event were documented, as follows: Staff heard a noise in resident room and intervened to find her on the floor behind the door. She was lying flat on her back with her head pointing towards the foot of the bed. She was noted to have sustained an abrasion to her right index finger. No further injuries noted from the fall, right index finger cleaned, and band aid applied, resident denies pain. The root cause of the incident was noted to be ambulating without her walker. Interview on 9/25/18 at 12:09 p.m. with the Licensed Practical Nurse (LPN) JJ in the conference room revealed the resident had an unwitnessed fall, and she, another LPN and a CNA picked the resident up from the floor and placed her in her bed. LPN JJ stated at that time, she completed a head-to-toe assessment. The nurse said the only injury was to the resident's finger. LPN JJ could not provide a rationale for picking the resident up from the floor before assessing her for injury. LPN JJ stated she realized she should have assessed the resident for injury before moving her. Interview 9/25/18 at 12:50 a.m. with the facility's DON in the conference room revealed the facility's fall protocol instructed nursing staff to assess the resident before moving the resident or getting them up. It was the expectation for nursing staff to assess a resident on the floor before moving them to determine if there were any injuries. She said all nursing staff were trained to complete an assessment of a resident before moving them. | 2020-09-01 |