| 5271 |
CAMBRIDGE POST ACUTE CARE CENTER |
115771 |
2020 MCGEE ROAD |
SNELLVILLE |
GA |
30078 |
2015-05-15 |
272 |
D |
0 |
1 |
PB4N11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility Resident Incident Log review, and staff interview, the facility failed to ensure the completion of Fall Assessments quarterly and/or after falls, per facility protocol, for two (2) residents (#43 and #134) from a survey sample of thirty-two (32) residents. Findings include: 1. Record review for Resident #43 revealed a Quarterly Minimum Data Set (MDS) assessment having an Assessment Reference Date of 04/06/2015 which documented an original facility admission date of [DATE]. Section I - Active [DIAGNOSES REDACTED].#43 had [DIAGNOSES REDACTED]. Section J - Health Conditions documented that Resident #43 had experienced two or more falls since admission. Additional review of the medical record of Resident #43 revealed a previous Quarterly MDS assessment and preceding Annual MDS assessment having Assessment Reference Dates of 11/23/2014 and 08/25/2014, respectively, which also documented the resident to have experienced two or more falls since admission. Additionally, a Significant Change MDS assessment was completed for Resident #43 on 01/10/2015. Review of the Fall Risk Assessments for Resident #43 revealed that Fall Risk Assessments had been completed on 02/26/2014, 05/21/2014, and 08/2014; however, there was no evidence of any Fall Risk Assessment having been completed for Resident #43 since the (MONTH) 2014 Fall Assessment referenced above. During an interview conducted on 05/15/2015 at 11:00 a.m. with the Assistant Director of Nursing (ADON), the ADON stated that resident Fall Risk Assessments were to be completed upon facility admission, quarterly, and after a fall. As indicated above, MDS assessments had been completed for Resident #43 on 11/23/2014, 01/10/2015, and 04/06/2014. In addition, the Care Plan of Resident #43 documented an actual fall from the bed on 04/12/2015 (with an updated Intervention indicating the addition of a floor mat). However, even though MDS assessments had been completed for Resident #43 on 11/23/2014, 01/10/2015, and 04/06/2014; even though the resident experienced an actual fall on 04/12/2015; and even though residents were to receive Fall Assessments quarterly and after a fall (per the ADON's 05/15/2015, 11:00 a.m. interview referenced above), there was no evidence to indicate that a Fall Assessment had been completed for Resident #43 since (MONTH) 2014 (nine months prior to this (MONTH) (YEAR) standard survey). During the 05/15/2015, 11:00 a.m. interview referenced above, the ADON acknowledged that the (MONTH) 2014 Fall Risk Assessment was the last Fall Assessment completed for Resident #43. 2. Record review for Resident #134 revealed a Quarterly MDS assessment having Assessment Reference Date of 04/07/2015 which documented in Section I - Active [DIAGNOSES REDACTED]. Section J - Health Conditions documented that Resident #134 had experienced two or more falls since admission. Additionally, the preceding Quarterly MDS assessment having an Assessment Reference Date of 01/12/2015 also documented, in Section J - Health Conditions, Resident #134 to have had two or more falls since admission. Review of the facility's Resident Incident Log for the previous six (6) months revealed that Resident #134 falls on the following days: 12/27/2014 01/04/2015 01/14/2015 03/25/2015 04/13/2015 During interview with the ADON conducted on 05/15/2015 at 10:50 a.m., the ADON stated that each resident should have a fall risk assessment completed at admission, quarterly, and after each fall. Review of Point Click Care (PCC) computer charting system for Resident #134 revealed that resident had Fall Risk Assessments completed on 01/23/2014, 04/17/2014, 04/27/2014, 07/10/2014, and 10/23/2014. There was, however, no evidence of any Fall Risk Assessment having been completed for Resident #134 after 10/23/2014, even though the resident had experienced falls on 12/27/2014, 01/04/2015, 01/14/2015, 03/25/2015, and 04/13/2015. During the 05/15/2015, 10:50 a.m. interview referenced above, the ADON acknowledged that Resident #134 had not had an updated Fall Risk Assessment since (MONTH) 2014 (as referenced above), and acknowledged that no Fall Risk Assessments had been completed after each fall that Resident #134 had experienced since the beginning of (YEAR). The ADON stated that Resident #134 had had five (5) falls with no injuries since the last Fall Risk Assessment, and that the resident should have had another Fall Risk Assessment completed due to multiple falls. |
2018-11-01 |