cms_GA: 7439
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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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 7439 | MOUNTAIN VIEW HEALTH CARE | 115688 | 547 WARWOMAN ROAD | CLAYTON | GA | 30525 | 2012-02-23 | 406 | D | 0 | 1 | D0IP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, the facility failed to arrange for provision of specialized services for one (1) resident (# 21) with a history of severe mental illness per the Preadmission Screening and Resident Review (PASRR) recommendation. The sample size was thirty-six (36) residents. Findings include: On 02/20/12 at 12:11 p.m., resident #21 was noted in their bed and appeared anxious and had several somatic complaints. Review of the resident's clinical record revealed they were admitted to the facility on [DATE]. Per the Admission Nurse's Note, the resident was admitted from a with [DIAGNOSES REDACTED]. A Mood State/Psychosocial Care Plan dated 03/30/11 noted the resident had depression and anxiety disorder, and was at risk for adverse moods, signs and symptoms of depression and behaviors related to difficulty coping with long-term care placement and decline in health. Interventions included to use diversional activities during care, such as holding onto a pillow, stuffed animal or other personal item as needed. There were no interventions for referral to psychiatric services. On admission the resident was receiving [MEDICATION NAME] and [MEDICATION NAME] for depression; [MEDICATION NAME] for anxiety; and [MEDICATION NAME] and [MEDICATION NAME] for [MEDICAL CONDITION]. The Georgia PASRR Psychiatric Evaluation and Medical History dated 03/17/11 noted that the resident had a chronic history of severe [MEDICAL CONDITION] with [MEDICAL CONDITION] and [MEDICAL CONDITION], generalized anxiety disorder and multiple medical problems. The PASRR Determination was that the resident had serious mental illness, met the Skilled Nursing Facility level of care criteria, and recommended specialized services for serious mental illness. Service Planning Recommendations included Crisis Services; Psychiatric Assessment/Care; Individual or Group Activity/Counseling; Case Management; and Day Supports. Rationale for Services Decision included frequent [MEDICAL CONDITION] and attempts in the past, and the need for evaluation of psych meds and close monitoring of these meds. Individual counseling was recommended due to severe anxiety and depression. Because of the resident's emotional health, close observation was needed. The resident's clinical record contained a letter that noted that the PASRR Level II review for resident #21 found that he/she was eligible to receive additional specialized services and/or supports according to an individualized plan of care to treat their serious mental illness. A fax number was provided for the facility to arrange for these specialized services. Review of the facility-provided Entrance Conference Worksheet noted that resident #21 was not on the list of residents receiving PASRR Level II services. Review of Skilled Daily Nurses Notes from 03/25/11 to 05/18/11 noted the Mood section was marked as showing the following indicators: Depression: On 34 days Restless/Fidgety/Anxious: On 45 days Tired/Little Energy: On 16 days Poor Appetite: On 2 days Little Interest/Pleasure in Doing Things: On 47 days Abnormal Sleep Patterns: On 9 days Inability to Concentrate: On 1 day Nurse's Notes dated 05/05/11 noted the resident complained of increased [MEDICAL CONDITION] and anxiety at night, and was unable to lay down due to their nerves. On 05/07/11 it noted the resident had increased anxiety and couldn't sit still due to nervousness and anxiety On 05/17/11 it was noted the physician was notified of the resident's depression, anxiety, and always nervous. A Physician Visit note dated 05/17/11 noted that she was requested to see the resident by the nursing staff as the resident continued to complain of [MEDICAL CONDITION]; stated their meds weren't working; got extremely anxious at night and couldn't sleep; needed something for their nerves as they were shaking and not able to sleep. The physician assessed the resident as having increased anxiety and [MEDICAL CONDITION], and a referral was made to a Behavioral Health Center (BHC) for medication evaluation and adjustment. The BHC History and Physical on admitted d 05/18/11 noted this was the resident's second admission to that facility, and was transferred from the nursing home due to severe agitation, anxiety and depression over the past several weeks, expressing suicidal comments; feeling very nervous and depressed with severe [MEDICAL CONDITION]. It noted the resident had several admissions with attempted suicide. The physician diagnosed the resident with recurrent severe major [MEDICAL CONDITION]; dementia with behavioral disturbance, and chronic mental illness. The resident was readmitted to the nursing home on 06/10/11. Review of the 30-day Minimum Data Set (MDS) on 06/30/11 and Quarterly MDS on 09/20/11 and 12/20/11 revealed the resident was not receiving any psychiatric therapy. An Initial Social Service (SS) History form dated 03/23/11 noted the reason for admission was long term care. The Significant Life Experiences and Significant Medical and Psychiatric History sections were blank. The next SS Progress Note Form dated 05/11/11 noted the resident's mood was depressed, had a history of [REDACTED]. On 02/22/12 at 10:00 a.m., Licensed Practical Nurse (LPN)HH stated that resident #21 was seen by their attending physician, but the resident was not seen routinely by any psych services. At 10:45 a.m., the SS Director (SSD) verified that the resident had been approved for Level II specialized services on 03/22/11, but had not been seen by psych services since he/she had been there. At 11:00 a.m., the SSD stated that unless there was an order on admission for a resident to be seen by psych services, they were not seen on a routine basis. | 2017-04-01 |