cms_GA: 3696
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 3696 | SMITH MEDICAL NURSING CARE CTR | 115691 | 501 EAST MCCARTY ST | SANDERSVILLE | GA | 31082 | 2019-11-01 | 657 | G | 1 | 0 | T47P11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record review, review of the facility's Falls Management policy, and staff interview, it was determined that the facility failed to evaluate the effectiveness of current interventions to prevent falls and failed to revise the FIP (Fall Intervention Plan) to include new interventions to prevent falls for one resident (R) (#1) of three residents reviewed for falls. This failure resulted in actual harm when R#1 sustained facial fractures after a fall on [DATE]. Findings include: Review of the undated facility policy titled Falls Management revealed that the goal of an intervention may not always be to prevent falls (but), to prevent injury .(Staff) should determine the cause of the fall and decide how a similar fall could be prevented for the resident (Staff) should update the FIP (Falls Intervention Plan) immediately and the date the intervention was put into place .At a minimum, the FIP will be reviewed with the MDS schedule and subsequent care plan review .A change in FIP should also trigger a note to explain reason for change (i.e , intervention no longer needed, intervention not working and why, etc.) .All falls should be reviewed daily by reviewing the medical chart to ensure that a new intervention was added to the FIP, evidence that an appropriate intervention was put into place to prevent further falls and the FIP updated. R#1 (a closed record) was admitted on [DATE] with [DIAGNOSES REDACTED]. The resident had a medical decline and was admitted to Hospice Services on [DATE] for severe dementia. R#1 expired on [DATE]. Review of the Quarterly Minimum Data Set (MDS) for R#1 dated [DATE] revealed that he had a Brief Interview for Mental Status (BIMS) score of 3 indicating that he had severe cognitive impairment. R#1 had a care plan dated [DATE] for falls related to the use of [MEDICAL CONDITION] medication with the following interventions for nursing staff: Provide safe, clutter free environment; call light within reach with prompt response to all requests; ensure resident wears appropriate well-fitting foot wear to minimize the risk of slipping; safety training and education as needed; and prompt to ask for assistance. R#1 had a fall on [DATE] at 3:30 p.m. Staff encouraged R#1 to call for assistance and wait until he was assisted. The FIP revealed that staff initiated an intervention on [DATE] for staff to ensure that the resident's call light was in reach and consider his cognition. There was no evidence that staff evaluated the appropriateness of the intervention with respect to his impaired cognition. R#1 had a fall on [DATE] at 6:10 p.m. The Incident/Accident Report for this fall dated [DATE] revealed that licensed nursing staff documented that steps taken to prevent further occurrence of falls was to send the resident to the ER. There was no indication that staff evaluated the appropriateness of the intervention (send to the ER) or updated the resident's FIP with an appropriate new intervention to prevent further falls with injuries. R#1 had a fall on [DATE] at 4:00 p.m. The Nurses Notes for [DATE] revealed steps taken to prevent recurrence was to keep the resident's call light in reach and consider his cognition. Nursing staff updated the resident's FIP with an intervention dated [DATE] for staff to educate the resident on how to use the call light and to consider his cognition. There was no indication that nursing staff evaluated the appropriateness of the [DATE] intervention to prevent further falls based on the resident's impaired cognition. R#1 had a fall on [DATE] at 6:10 a.m. The Incident/Accident Report for the fall dated [DATE] revealed that there was no indication that nursing staff updated the FIP with appropriate interventions to prevent further falls with injuries. Review of the Significant Change MDS assessment dated [DATE] revealed that R#1 had a BIMS of 99, indicating severe cognitive impairment. Review of his care plan dated [DATE] and reviewed [DATE], [DATE] and [DATE] revealed the same interventions as his [DATE] care plan with the addition of an intervention for two staff to transfer the resident. R#1 had a fall on [DATE] at 5:50 p.m. The Incident/Accident Report for the fall dated [DATE] revealed that steps taken to prevent further recurrence were to monitor the resident frequently and encourage him to wait for assistance as needed. The FIP was updated on [DATE] with an intervention for staff to keep the call light in reach and consider the resident's cognition. There was no indication that nursing staff evaluated the appropriateness of the interventions or considered the resident's severe cognitive impairment. R#1 had a fall on [DATE] at 9:00 a.m. The Incident/Accident Report dated [DATE] revealed that steps taken to prevent recurrence was to recline the resident's Geri-chair. There was no indication that staff updated the resident's FIP to include the use of the Geri-chair or to keep it reclined. R#1 had a fall on [DATE] at 9:55 a.m. The physician ordered staff to place a tray on the resident's Geri-chair for safety. The FIP was updated to include the intervention of the tray but, there was no date documented as to its initiation. review of the resident's medical record revealed [REDACTED]. However, staff failed to update the FIP to indicate that the tray was discontinued. R#1 had a fall on [DATE] at 3:50 p.m. and sustained acute traumatic fractures of the left maxillary wall and left lateral orbital wall. The Incident/Accident Report for the fall dated [DATE] revealed that the steps taken to prevent recurrence was to monitor the resident closely. However, there was no indication as to the frequency of the monitoring (i.e., every 15 minutes, every 30 minutes, etc.). On [DATE], the physician ordered staff to place a floor mat next to the resident's bed. However, the FIP was not updated to include the fall mat. During an interview on [DATE] at 12:59 p.m., LPN AA stated that the nurse who completes the Incident/Accident Report is responsible for documenting a new intervention on the FIP. Further interview revealed that she notifies the on-coming nurse about the fall and the new intervention. Interview with the Director of Nursing (DON) on [DATE] at 3:46 p.m. revealed that the nurse was responsible for completing the Incident/Accident report after each fall and documenting an appropriate intervention to address the fall. Continued interview revealed that incidences that occurred the previous 24 hours including falls were discussed in the morning meeting. Staff determined the cause of a fall if possible and ensured that interventions were in place as care planned. The DON stated that she reviewed the Incident/Accident Report to ensure that any new interventions were appropriate. On [DATE] at 1:43 p.m., the DON reviewed the falls for R#1. She confirmed at that time that the intervention to keep the call light within reach and encourage the resident to use his call light and wait for staff to assist him was inappropriate based on his cognitive impairment for the falls on [DATE], [DATE] and [DATE]. Continued interview revealed that staff did not attempt to initiate a fall mat as an intervention on [DATE], [DATE] or [DATE] as a means to prevent injuries until after his [DATE] fall with major injury (facial fracture). Further interview revealed that the tray for the Geri-chair was discontinued on [DATE] and staff removed the tray without updating the care plan. Cross Refer to F689. | 2020-09-01 |