cms_GA: 33
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 33 | NORTH DECATUR HEALTH AND REHABILITATION CENTER | 115012 | 2787 NORTH DECATUR ROAD | DECATUR | GA | 30033 | 2018-12-06 | 656 | E | 0 | 1 | 46UW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews the facility failed to develop a plan of care to address activities of daily living (ADL's) for one resident (R#38), Oxygen usage for two resident (R#3, R#29) and failure to implement care plan intervention for one resident (R #55) related to Restorative Nursing for Range of Motion (ROM) and one resident (R #214) for ADL care. The sample size was forty residents. Findings include : Review of the clinical record for R#3 revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. She had no known drug allergies and elected full code status. Review of the physician's orders [REDACTED]. Review of the most recent Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 13, indicating she was cognitively intact; a Mood Total Severity Score of 0, indicating she was not depressed; and displayed no behaviors. Continued review of the same assessment documented R#3 as using oxygen while a resident. Review of the care plan, updated 11/28/18, did not include a care plan for oxygen to include goals and interventions. Observation and interview with R#3 on 12/03/18 at 12:25 p.m. revealed R#3 was wearing O2 via NC at 4.5 LPM. When asked if she knew what her O2 liter flow was supposed to be, she stated she believed her physician order [REDACTED]. She stated she was in no respiratory distress. Observation and interview with R#3 on 12/04/18 at 1:14 p.m., she was alert, oriented and pleasant sitting up in her wheelchair in her room. She was wearing O2 at 3 LPM via NC using a portable E-cylinder. She stated she was in no respiratory distress. Observation of R#3 on 12/04/18 at 4:49 p.m., noted she was asleep wearing O2 via NC at 3 LPM. She was in no apparent respiratory distress. Observation and interview of R#3 on 12/05/18 at 8:40 a.m., R#3 was seated upright in her bed wearing O2 via NC at 3 LPM. She stated she had just finished breakfast and was in no respiratory distress. Observation and interview with R#3 on 12/06/18 at 9:40 a.m., revealed she was wearing O2 via NC at 3 LPM. She stated she was in no apparent distress. Review of the vital signs for R#3 revealed an admission, 7/24/18 at 19:24 (7:24 p.m.), blood O2 saturation 99% on room air, which indicated her hemoglobin was adequately saturated with O2. Further review of O2 saturations for R#3 revealed an O2 saturation of 96% on 7/26/18 at 6:57 a.m. on O2 via NC. No O2 liter flow was documented. Continued review of O2 saturations for R#3 revealed an O2 saturation of 96% on O2 on 12/3/18 at 6:29 a.m.; 96% on O2 on 12/3/18 at 16:04 (4:04 p.m.); and 98% on O2 on 12/4/18 at 00:29 (12:29 a.m.). None of the O2 saturation readings reviewed indicated an O2 liter flow. In an interview with the Area Resident Care Manager (RCM) Director 12/6/18 at 11:34 a.m. regarding the contents of the care plan, she confirmed O2 was not included in the initial care plan or subsequent care plan updates. She identified facility issues such as the resignations of the MDS Director in (MONTH) (YEAR) and the MDS Coordinator in (MONTH) (YEAR) which delayed care plan and MDS updates and assessments. The Area RCM Director further explained the Sava (corporate) process for completion of the MDS assessment included reviewing the clinical record, speaking to the staff directly involved in resident care and resident interviews. 2. A review of the clinical record for R #38 revealed resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's most recent Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as 10, which indicated mild cognitive impairment. Section G revealed that the resident was assessed for total dependence for dressing, toilet use and personal hygiene. Review of updated care plan for R#38, dated 8/1/18, did not have evidence that R#38 had a care plan problem to include assistance needed with Activities of Daily Living (ADL) care. Observation on 12/3/18 at 1:49 p.m., 12/4/18 at 3:05 p.m., and 12/5/18 at 9:06 a.m., revealed that fingernails on both hands have dark brown material underneath and are untrimmed. 3. A review of the clinical record for R #214 revealed resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #214 is a new admission and entry tracking Minimum Data Set ((MDS) dated [DATE] is only MDS available, therefore, no data available at this time. Review of care plan initiated 11/28/18 resident has activity of daily living self-care deficit related to left hip pain, difficulty walking and malaise. Interventions to care include encourage active participation in tasks, receives extensive to total care for baths, staff to do nail care, allow sufficient time to perform tasks and praise resident for all efforts at self-care. Observation on 12/3/18 at 12:48 p.m., 12/4/18 at 11:02 a.m., and 12/5/18 at 10:09 a.m., and 12/6/18 at 8:30 a.m. revealed that nails are untrimmed and dirty underneath on both hands. Resident stated he would like for them to be trimmed. 4. A review of the clinical record for R #29 revealed resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's most recent Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as 13, which indicated no cognitive impairment. Section O revealed that the resident was assessed for Oxygen use while a resident. Interview on 12/6/18 at 1:11 p.m., with Registered Nurse (RN) CC stated that the Minimum Data Set (MDS) nurses do the initial care plan after the Admission Assessment is completed. She further stated that the interdisciplinary team (IDT) team can add to the care plan at any time and after the quarterly assessments are completed. During further interview, she verified that the facility has been without an MDS nurse for three weeks. She stated that she visits the facility daily and does MDS assessments when she visits. She further stated that other MDS nurses employed by corporate help out as well. Interview on 12/6/18 at 4:17 p.m., with RN BB stated that it is her expectation that the MDS nurses generate care plan for each area of concern that the resident will need to be addressed while a resident in the facility. Interview on 12/6/18 at 4:32 p.m., with RN BB verified that R#29 did not have a care plan to address his daily use of Oxygen therapy. 5. Review of resident (R#55's) medical record revealed the resident was admitted to the facility on (MONTH) 13, (YEAR) with [DIAGNOSES REDACTED]. Further review of R#55 medical record revealed his Minimum Data Set (MDS) quarterly assessment dated (MONTH) 3, (YEAR) indicated that R #55 has impairments to one side on the upper extremities and has impairments of both legs on the lower extremities. Additionally, according to resident Minimal Data Set he is receiving Restorative Services for 6 weeks with splinting devices. Review of R#55 care plans indicated that he was care plan for receiving Restorative Care for splint/brace assistance. The goal for R#55 was for him to achieve the highest level of optimal functioning with splinting over the next six weeks, the interventions included splinting to left elbow extremity with splint for first eight hours. Review of resident physician orders [REDACTED].#55 to have splinting brace on left elbow extremity and left resting hand splint with digit separator for first eight hours with skin checks. Program scheduled for six days a week for six weeks. Observation made on 12/04/18 at approximately 10:38 a.m revealed resident R#55 left hand contracted while in bed asleep without splinting device in place. At the time of the observation the splint was observed lying on his dresser beside him. Observation made on 12/05/18 at 1:34 p.m revealed resident R#55 in his bed asleep with the splinting device lying on top of the dresser beside him. Observation made on 12/05/18 at 2:44 p.m revealed resident R#55 in his bed awake with splinting device on his dresser. Review of resident restorative log for the month of (MONTH) (YEAR) through (MONTH) (YEAR) indicated there were no documented refusals of R#55 refusing to wear splinting devices. Additionally, there were no documented times to show when restorative aids place splinting devices on and off the R#55. On (MONTH) 5, (YEAR) at 02:15 p.m an interview was conducted with Certified Nursing Assistant (CNA) GG she stated that R#55 was supposed to have his splint brace on for eight hours a day and that she put his splint on earlier doing the shift but remove it after 2:30 p.m. She also stated that he cannot make his needs known and he rarely refuses care. On (MONTH) 5, (YEAR) at 3:30 p.m an interview was conducted with the Director of Clinical Services. She stated that R#55 should've had his splint on for the shift unless he refused care. She also stated that the Minimal Data Set Coordinator is responsible for making sure restorative is caring out their duties but at this time they currently do not have a MDS coordinator that oversees restorative nursing duties. Additionally, She did state that they are in the process of training an individual to take over for MDS at this time. | 2020-09-01 |