cms_GA: 29

In collaboration with The Seattle Times, Big Local News is providing full-text nursing home deficiencies from Centers for Medicare & Medicaid Services (CMS). These files contain the full narrative details of each nursing home deficiency cited regulators. The files include deficiencies from Standard Surveys (routine inspections) and from Complaint Surveys. Complete data begins January 2011 (although some earlier inspections do show up). Individual states are provides as CSV files. A very large (4.5GB) national file is also provided as a zipped archive. New data will be updated on a monthly basis. For additional documentation, please see the README.

Data source: Big Local News · About: big-local-datasette

This data as json, copyable

rowid	facility_name	facility_id	address	city	state	zip	inspection_date	deficiency_tag	scope_severity	complaint	standard	eventid	inspection_text	filedate
29	NORTH DECATUR HEALTH AND REHABILITATION CENTER	115012	2787 NORTH DECATUR ROAD	DECATUR	GA	30033	2017-02-09	514	D	0	1	OC5011	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview and review of policy and procedure, the facility failed to maintain accurate clinical records for two residents (R), (R#77) related to [DIAGNOSES REDACTED].#59) related to inaccurate documentation of gastric tube feedings from a sample of 27 residents. Findings include: Review of facility policy titled Medication Review - Admission/ReAdmission revealed Medication review is intended to eliminate prescribing medication errors at care transitions by generating a complete and accurate list of resident medications. The second medication review will include review of admission orders [REDACTED]. 1. Review of the clinical record for R#77 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Continued review revealed R#77 was a male. Review of the hospital clinical record for R#77 revealed he had been admitted on [DATE] and discharged to the facility on [DATE] and had not had surgery during his hospital admission. Transfer orders from the hospital for R#77, dated 12/27/16, included an order for [REDACTED]. Facility admission orders [REDACTED]. Review of the December, (YEAR) and January, (YEAR) MAR for R#77 revealed [MEDICATION NAME] 250 mg had been initialed as administered at 9:00 a.m. on 12/28/16, 1/2/17, 1/3/17 and 1/4/17. Interview 2/9/17 at 11:45 a.m. with the Director of Nurses (DON) revealed the [DIAGNOSES REDACTED]. The DON acknowledged the order for [MEDICATION NAME] had been transcribed incorrectly and recorded as administered incorrectly. The DON revealed the process for avoiding transcription errors for newly admitted residents is to review the MAR/TAR and compare with the admission orders [REDACTED]. The DON revealed she had compared the admission and transfer orders with the MAR for R#77 but had not noticed there was only one space to sign out [MEDICATION NAME] 250 mg on the MAR and that the spaces for 12/29/16, 12/30/16, and 12/31/16 had been crossed out. The DON revealed she also had not noted the error in the [DIAGNOSES REDACTED]. Interview 2/9/17 at 3:30 p.m. with the Administrator revealed she had checked pharmacy records and [MEDICATION NAME] 250 mg had been delivered for R#77. She indicated after checking medication disposition records for the [MEDICATION NAME] for R#77 had not been destroyed or returned to the pharmacy. The Administrator revealed the nurse who transcribed the admission orders [REDACTED]. Review of pharmacy disposition records for the month of (MONTH) indicated there had been no [MEDICATION NAME] destroyed or returned to the pharmacy. Review of Pharmacy dispensing records indicated six [MEDICATION NAME] 250 mg tablets were delivered to the facility on [DATE] for R#77. 2. Review of the Physician orders [REDACTED]. every shift and to administer [MEDICATION NAME] per the [DEVICE] as ordered Review of the MAR revealed the following missing documentation for the administration of the water flushes: 10/16/16 at 6:00 a.m. 10/28 at 6:00 a.m. 11/11/16 at 12:00 a.m. and 6:00 p.m. 11/12/16 at 6:00 a.m. 11/15/16 at 12:00 p.m. and 6:00 p.m. 11/16/16 at 12:00 p.m. and 6:00p.m. 12/17/16 at 7:00 a.m. Review of the MAR revealed the following missing documentation for the checking GT placement: 10/16/16 10/31/16 11/16/16 11/25/16 1/17/17 2/5/17 at 7:00 a.m. Review of the MAR revealed the following missing documentation for [DEVICE] feedings: 11/2/16 at 1:00 a.m. and 5:00a.m. 11/3/16 at 9:00a.m. 11/11/16 at 5:00 p.m. and 9:00 p.m. 11/15/16 at 5:00 p.m. 11/16/16 at 1:00 a.m. 12/14/16 at 1:00 p.m. 12/16/16 at 1:00 p.m. 12/20/16 at 1:00 p.m. 12/24/16 at 5:00 p.m. 1/17/17 at 1:00 p.m. 2/2/17 at 1:00 p.m. During an interview on 2/9/17 at 6:15 p.m., the Director of Nursing (DON), confirmed there were holes and missing documentation on the MARs and she further stated her expectation is for the nurses to document when they give the medication and/or treatments.	2020-09-01