cms_GA: 41
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 41 | NORTH DECATUR HEALTH AND REHABILITATION CENTER | 115012 | 2787 NORTH DECATUR ROAD | DECATUR | GA | 30033 | 2018-12-06 | 883 | D | 0 | 1 | 46UW11 | Based on resident interviews, staff interviews record review and policies titled Immunizations: Influenza (Flu) Vaccination of Residents and Staff and Standing Orders for Administering Pneumococcal Vaccines to Adults; the facility failed to document rationale of resident (R)#24 refusal of Flu and provide vaccine information statement (VIS) and offering of Pneumococcal vaccine and VIS to R# B. Sample was 2 of 5. Findings include; During review of facility's infection control processes on 12/6/18 at 11:41 a.m. unable to locate documentation for R#24 regarding refusal of flu vaccine. Also, unable to locate documentation that education via the VIS as recommended by the Center for Disease Control (CDC) was provided to resident and /or family member. Further review of R#24's minimum data set (MDS) which a is part of the United States federally mandated process for clinical assessment of all residents in Medicare or Medicaid certified nursing homes; assessed R#24 with a Brief Interview for Mental Status (BIMS) of two. BIMS is a test given by medical professionals that helps determine a patient's cognitive understanding. A score of 00-07 indicates severe cognitive impairment. R#24 has family member who is the responsible party (RP). An interview with Director of Nursing (DON), with Corporate representative present, Director of Clinical Services, on 12/6/18 at 12:00 p.m. revealed that the electronic medical record (EMR) should show that the resident and /or RP was provided the VIS education. DON attempted to evidence the education had been given. Upon continued review of the R#24's record DON was unable to confirm the VIS education was provided; Nor was there evidence of a nurse's note indicating VIS education had been provided or discussed. On 12/6/18 at 12:55 p.m. Corporate representative, Director of Clinical Services provided a document dated 12/6/18 indicating the resident's RP had been contacted to discuss administration of the flu vaccine. The RP refused however; the reason for refusal not documented nor was it clear that the VIS was used to discuss the risks and benefits of the vaccine. An interview on 12/6/18 at 1:20 p.m. with DON and Director of Clinical Services present, revealed resident was offered the Pneumonia vaccine upon his admission in on 6/4/18. Four days after his admission. DON further stated no conversation about pneumonia took place this current flu season. An interview on 12/6/18 at 1:30 p.m. RB revealed does not remember when last received the pneumonia vaccine. Further stated that no one discussed administration on the pneumonia vaccine either upon his admission in (MONTH) (YEAR) or during this current flu season. R B has a BIMS of 10. A score of 08-12 indicates moderate cognitive impairment. RA was able to answer screening questions without difficulty; cohesively and coherently. Review of facility's policy titled Immunizations: Influenza Vaccination of Residents and Staff revised 2/2018 states on page 29 under Administration procedure bullet point B states; the VIS will be used to discuss the risks and benefits of the vaccine. In the case of residents this may be with their authorized representative when appropriate. Bullet point C states; Resident may refuse vaccination. Vaccination refusal and reason why should be documented. Review of facility's policy titled Standing Orders for Administering Pneumococcal Vaccines to Adults, no date, states on page two of four, bullet #3; provide all patients with a copy of the most current federal VIS. | 2020-09-01 |