cms_GA: 77
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 77 | GLENWOOD HEALTH AND REHABILITATION CENTER | 115025 | 4115 GLENWOOD RD | DECATUR | GA | 30032 | 2016-07-28 | 323 | D | 0 | 1 | 44GN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record, and facility policy review, the facility failed to provide adequate supervision for 1 sampled resident (Resident #61) from a sampled 31 residents. On 4/26/16 Resident #61 had expressed a desire to leave the facility, however the resident could not leave the facility unless accompanied by a family member. The facility was not aware the resident had left the facility unsupervised until 10 pm on 4/26/16. Findings include: Review of the facility's policy titled Elopement revised 2013 revealed the following information elopement is defined as that situation where a resident with impaired decision making ability , who is oblivious to his/her own safety, needs and therefore at risk for injury outside the confines of the living center, has left the living center without knowledge of staff. Review of Resident #61's active clinical record revealed the resident was readmitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Minimum Data Set (MDS), Medicare 30 day, indicated the resident was cognitively intact with a score of 13. -Quarterly MDS, dated [DATE] indicated the resident displayed no wandering behavior not exhibited and required supervision with all activities of daily living. Review of Care plans initiated on 3/11/16 revealed the following: Focus: - Resident #61 has impaired neurological status related to: Parkinson's disease, Dementia Focus: I forget things and can become anxious and it can create possible safety risks for me related to [DIAGNOSES REDACTED]. Review of the resident ' s progress notes revealed a late entry note dated 4/26/16 11:02Note Text: Resident noted to have left the faciity on this date without signing out. Resident's emergency contact person was called to determine if resident was picked up early for pending discharge. Family denies discharging resident early and stated that they were unaware of where resident may have gone. Resident was scheduled to be discharged to a PCH on 4-27-16 and was aware of this plan. Resident was present during discharge care plan meeting and was in agreement with discharge. Facility notified appropriate authorities and followed facility protocol for procedural variance. Resident is discharged from facility. The facility ' s investigation concerning this incident contained staff interviews and review of the facility monitoring tape. The investigation documents staff first identified the resident as missing around 10:45 PM, when it was noticed by the 3- 11 shift Charge Nurse who did not give the resident his medication because he was not in his room. Evening shift nurse stated medications were not administered to the resident during the shift since he was not present. CNA also reported to the charge nurse that she did not see the resident early in the shift. Documentation indicated on 4/26/16, before noon the resident was at the Dogwood unit and approached the nurse ' s station requesting to be signed out. Resident was told at that time that sister or niece needs to be with resident in order for him to sign out. Staff was aware that the resident wanted to leave the facility and the front desk was notified to keep an eye out for the resident. Review of facility ' s staff statements indicated housekeeping staff saw Resident #61 on the[NAME]bus at 3:30 pm and then the resident transferred to the[NAME]train between 4:00 - 4:15 pm. Afternoon Nurse PP stated I was assigned to Resident #61 around 5:00 pm when I was informed that the nurse who was supposed to come in for the GA/Dogwood cart (unit where resident ' s room was located) had not shown up . Between 7:30 - 8:00 pm I was asked by the CNA where Resident #61 was. I told her I wasn ' t ' sure and to ask the nurse assigned to him to see if she had seen him. Shortly thereafter when the primary nurse assigned to Resident #61 asked me had I seen him I stated that I had not seen him since around 2:30 pm in the front lobby looking out of the window On 7/25/16 at 4:39 PM. interview with Social Worker CC was conducted concerning residents who are assessed for elopement risk. SW CC stated the facility has a safety committee that meets concerning all residents who are risk for elopement. An assessment is completed and those who are risk for elopement have wander-guard bracelets placed on them. Social worker completes an elopement care plan for those residents at risk and the 3-11 PM nurses check all wander guards, to make sure the residents have them on. On 7/28/16 at 2:40 PM, the Director of Nursing (DON) and the Executive Director were interviewed concerning Resident # 61 who went missing from the facility on 4/26/16. The Executive Director stated the resident was not considered an elopement risk because he had never left the grounds before that day without anyone with him. Also, the resident was aware that he was being discharged to a personal care home the next day. When asked about the resident's [DIAGNOSES REDACTED]. We watched the tape and he planned to leave, He timed when the bus was coming and walked right out there and got on the bus. When asked why staff did not know the resident had left until 10:45 PM. the Executive Director and the DON both stated he was a very social guy and was rarely in his room. Executive Director and DON were asked why Resident #61 was being discharged to a personal care home, for what reason. Executive Director replied he was being discharged to a personal care home because that is where his family wanted him to go . When asked about the care plan that indicated the resident forgot things, became anxious and this was noted to create safety risks for the resident. DON stated he could make his needs known The facility was aware the resident wanted to leave but failed to provide closer monitoring of the resident ' s whereabouts. Several hours went by before the facility realized the resident was missing. | 2020-09-01 |