cms_GA: 50

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

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rowid facility_name facility_id address city state zip inspection_date deficiency_tag scope_severity complaint standard eventid inspection_text filedate
50 BELL MINOR HOME, THE 115020 2200 OLD HAMILTON PLACE NE GAINESVILLE GA 30507 2016-11-10 514 D 0 1 M6O611 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews, the facility failed to ensure documentation for the use of a splint or refusal to use a splint for one (1) resident (R) (R#65) with a left hand contracture and failed to consistently document the urinary output for one (1) resident (R#93) with a urinary catheter. The sample was thirty six (36) residents. Findings include: 1. Record review for resident #65 revealed an Annual Minimum Data Set (MDS) assessment dated [DATE] revealed the [DIAGNOSES REDACTED]. Review of the care plan for R#65 dated 8/8/2016 indicated a left hand contracture [MEDICAL CONDITION] secondary to history of [MEDICAL CONDITION]. The goal of the facility is to minimize decline in left hand contracture. An intervention included to place splint as tolerated and maintain contracture and treatment prn as ordered. Review of restorative nursing care weekly notes dated 8/25/16 documented: range of motion active, transfer, dressing or grooming fair. The resident making fair progress towards goals. Continue with restorative nursing program. Observations of R#65 revealed a left hand contracture with no splint device in place on 11/09/2016 at 9:56 a.m. and 11/9/2016 at 12:00 p.m. An interview with R#65 on 11/9/2016 at 9:56 a.m. revealed the left hand contracture was the result of a past stroke. R#65 further stated she is unable to use her left hand to assist with any daily activity. Review of restorative CNA progress notes section dated 8/25/16 documented: range of motion active, training skill/practice: transfer/dressing or grooming progress is fair towards goals. Further review of the clinical record for R#65 revealed no evidence of documentation when the splint was placed or if the splint was tolerated by the resident. Further Record Review revealed no evidence of documentation related to (r/t) splint and/or refusal of splint wearing. Review of care plan revealed left hand contracture with intervention to splint as tolerated-no issues Interview with Charge Nurse OO on 11/10/2016 at 11:33 a.m. revealed the R#65 is not on restorative care services at this time and is able to eat without assistance, R#65 does not need restorative care services. This is documented in the Electronic Medical Record (EMR) and there are not any recommendations for restorative care for the resident. Interview with Certified Nursing Assistants (CNAs) MM and NN on 11/10/2016 at 1:55 p.m., revealed R#65 was on restorative care services previously for splint use as tolerated. CNA MM stated that R#65 refused to wear the hand splint. When asked if this information was documented, CNA's MM and NN were unaware if refusal of splint treatment was documented in the EMR. Interview with the Administrator on 11/10/2016 at 3:21 p.m., that the hand splint treatments, and restorative care services for R#65 was not documented for either the use of or refusal of wearing the hand splint as tolerated per the care plan. 2. Review of the policy for recording input and outputs documented that the facility will ensure that fluid intakes and outputs are calculated and recorded every twenty four (24) hours. R#93 was admitted to the facility on [DATE] with a urinary catheter for [MEDICAL CONDITION] and acute kidney injury. R#93 was discharged on [DATE] and re-admitted on [DATE] with continued urinary catheter. Review of the Physician orders [REDACTED]. Review of Medication Administration Record [REDACTED]. Interview on 11/10/2016 at 9:10 a.m. with the Certified Nursing Assistant (CNA) GG revealed that urinary outputs are recorded on the vital signs sheet which is provided by the nurse at the start of the shift. Outputs are recorded twice per shift (at the beginning and at end of the shift) and the vital signs sheet is handed back to the nurse for input into the computer. Interview on 11/10/2016 at 9:23 a.m. with the Licensed Practical Nurse (LPN) FF revealed that urinary output is recorded by the CNA on the vital signs sheet which she gives the CNA at the start of the shift. The CNA returns the form to the nurse at the end of the shift and at that time the nurse records the total output on the computer system. Interview on 11/10/2016 at 10:35 a.m. with the Director of Nursing (DON) revealed that the CNAs are expected to record urinary output on vital signs sheet and then hand the sheet over to the nurse at some point in their shift to enter it on the computer. The DON stated she expects the urinary output to be entered in the computer on each shift. 2020-09-01