cms_GA: 31
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 31 | NORTH DECATUR HEALTH AND REHABILITATION CENTER | 115012 | 2787 NORTH DECATUR ROAD | DECATUR | GA | 30033 | 2018-12-06 | 636 | D | 0 | 1 | 46UW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, record review and policy titled Resident Assessment Instrument process, the facility failed to assess the resident (R) #24 on the Minimum Data Set (MDS) assessment for depression. Sample size was 37. Findings include; R#24 was admitted on [DATE]. [DIAGNOSES REDACTED]. During an unnecessary medication record review on 12/4/18 at 1:46 p.m. a review of R#24 medications include but not limited to [MEDICATION NAME] 10 mg 1 tab daily by mouth (po) for depression, [MEDICATION NAME] .5mg po for agitation at hour of sleep, (hs) and [MEDICATION NAME] 5mg daily for dementia. Further record review revealed Pharmacy Consultant reviewed R#24 record on 10/17/18 and made a recommendation to attempt a gradual dose reduction (GDR) for [MEDICATION NAME]. On 10/29/18 the Physician documented a GDR was contraindicated for this resident and declined the pharmaceutical recommendation. Continued review of R#24 record offers evidence resident was receiving psychiatric services and was last seen on 11/26/18. The review of records revealed a Nurse Practioner assessed resident on 11/12/18. The active problem list included a [DIAGNOSES REDACTED]. Review of several of R#24's most recent MDS did not assess the resident as having depression. MDS reviews included an annual dated 12/2/17 and quarterly's dated 2/7/18, 4/24/18, 7/10/18, and 9/19/18. Review of care plan revealed the resident is care planned for review of [MEDICAL CONDITION] medications. An interview with the Director of Nursing (DON) on 12/6/18 at 10:00 a.m. revealed the facility has been without a fulltime MDS Coordinator for more than 30 days. DON continued to state that corporate personnel and staff members from other facilities have been filling the positions. A telephone interview on 12/6/18 at 11:23 a.m. with, Regional Nurse Resident Assessment Consultant (RAC) revealed the MDS Coordinator is responsible for reviewing all MDS's in the facility. In clinical morning meetings what should take place is a review of orders to ensure there are corresponding [DIAGNOSES REDACTED]. There has been a lot of turnover. An interview with Corporate Area Resident Care Management Director (RCMD) on 12/6/18 at 12:00 p.m. stated she has been with the company since (MONTH) (YEAR). Stated she has identified care plan update issues. Her position is to come into the facility on and off to train the MDS Coordinator. The RCMDF Continued to state that now she comes to facility on a regular basis, especially since both staff members in MDS department resigned in (MONTH) and (MONTH) (YEAR). Continued interview indicated the process to ensuring the MDSs are accurate is to review the resident record, speak to staff and conduct resident interviews. Currently a new MDSs coordinator had been hired and is in orientation. An interview on 12/06/18 at 2:01 p.m. with Area RCMD confirmed R#24 had not been assessed for depression on the MDSs. Continued to state they just in put the [DIAGNOSES REDACTED]. Review of facility policy dated (MONTH) (YEAR) titled Resident Assessment Instrument (RAI) process states, on page 2 of 6, under procedure; the facility conducts a comprehensive assessment (MDS) to identify the resident's needs, strengths, goals, life history, and preferences within 14 days after admission (Initial admission assessment). This excludes readmissions where there is no significant change in the resident's physical or mental condition. The assessment must include at the following: j. Disease [DIAGNOSES REDACTED]. | 2020-09-01 |