cms_GA: 650
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 650 | ZEBULON PARK HEALTH AND REHABILITATION | 115295 | 343 PLANTATION WAY | MACON | GA | 31210 | 2019-11-15 | 656 | D | 0 | 1 | GS7J11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and staff interviews the facility failed to follow the care plan for two of 32 sampled residents (R) (#154 and R#28). Findings include: 1. Review of the electronic medical record (EMR) for R#154 revealed a [DIAGNOSES REDACTED]. Further review of the EMR revealed a care plan for altered nutritional status related to no free-standing water with an onset date of 11/7/19. Interview with Resident Care Coordinator (RCC) CC on 11/15/19 at 11:15 a.m. who confirmed that there were two cups of water in resident's room. RCC CC reported that there should be no cups or water in resident's room due to fluid restriction and this information is listed on resident's care plan. Observation on 11/13/19 at 8:14 a.m. revealed R#154 in bed in room with a cup of water on nightstand dated 11/12/19, 11-7. Observation on 11/14/19 at 8:20 a.m. revealed R#154 in bed in room with a cup of water noted on her over bed table. Observation on 11/15/19 at 9:25 a.m. revealed a cup of coffee 1/4 full and a full cup of water in R#154's room. Interview on 11/15/19 at 11:23 a.m. with Licensed Practical Nurse (LPN) DD who reported that she was aware that the water cup and coffee was in resident's room. LPN DD was not aware that the care plan indicated no water at the bedside. Cross Refer to F684. 2. A review of the medical record for R#28 revealed resident was admitted to the facility with [DIAGNOSES REDACTED]. Review of the care plan, revised on 9/26/19, revealed that R#28 is at fall risk related to history of falls, with a fall risk score of 12. Continued review revealed that the resident has a scoot chair, and balance concerns, along with impaired memory. Review of the Interventions include, but not limited to the following: non-skid socks/non-skid shoes; place resident in an open area for maximum observation opportunities; anticipate resident's needs; check on resident frequently; and have a fall mat on both sides of bed. Observation on 11/12/19 at 12:07 p.m., R#28 was observed seated in a scoot chair, leaning forward in the day room, without nonskid sole socks and/or shoes. Observation on 11/13/19 at 8:51 a.m., resident was observed sitting in scoot chair in day room alone, leaning forward with eyes closed, without non-skid sole socks and/or shoes. Another observation at 1:23 p.m., revealed that R#28 was lying in bed awake, with a fall mat on left side only of bed and another fall mat leaning on wall. At 3:14 p.m., R#28 was lying in bed with eyes closed, fall mat on left side of bed, and another fall mat leaning on wall. Observation on 11/14/19 at 10:58 a.m., R#28 observed in day room sitting in scoot chair, awake without non-skid socks and/or shoes. Interview on 11/15/19 at 12:31 p.m. with the Director of Nursing (DON), says she expects her staff to review and implement residents Activities of Daily Living (ADL) plan of care/care plans daily at the start of their shift in order to provide the care needed for the residents. Interview on 11/15/19 at 1:50 p.m. with Licensed Practical Nurse (LPN) CC stated that she as well as other staff, are responsible for completing plan of care/care plans for residents, so that the Certified Nursing Assistants (CNA) may review. She confirmed that non-skid socks were on both the ADL plan of care and care plans. | 2020-09-01 |