cms_GA: 8076
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 8076 | WYNFIELD PARK HEALTH AND REHABILITATION | 115625 | 223 W.THIRD AVENUE | ALBANY | GA | 31701 | 2012-03-29 | 312 | E | 0 | 1 | LF6S11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, it was determined that the facility failed to ensure that four residents' (#11, #45, W and #113) fingernails were clean and trimmed, that two residents' (#45 and W) were shaved and that one resident (A) was provided oral care from a total sample of 36 residents. Findings include: 1. Resident #11 was coded by the facility on the 2/10/12 quarterly Minimum Data Set (MDS) assessment as needing total assistance from staff for personal hygiene. The resident had a care plan intervention since 3/22/10 for total care by nursing staff including nail care. However, the resident was observed with a thick black substance underneath his/her fingernails on 3/27/12 at 8:15 a.m. and 5:00 p.m., and on 3/28/12 at 7:55 a.m. and 11:20 a.m. 2. Resident #113 was coded by the facility on the 1/6/12 quarterly MDS assessment as needing total assistance from staff for hygiene. The resident had a 5/21/11 care plan intervention for staff to provide assistance with activities of daily living (ADL). However, the resident was observed with a thick black substance underneath his/her fingernails on 3/28/12 at 8:15 a.m. and 2:00 p.m. and on 3/29/12 at 8:15 a.m. 3. Resident W was coded by the facility on the 2/02/12 MDS for annual comprehensive assessment as needing total assistance from staff for personal hygiene, toilet use, dressing, transfer and bathing. The resident had a care plan intervention since 2/16/12 for direct care staff to provide assistance with all ADLs. However, the resident was observed with long and dirty nails on 3/26/12 at 3:30 p.m., on 3/27/12 at 4:00 p.m., 3/28/12 at 8:50 a.m., 1:00 p.m. and 4:00 p.m. and on 3/29/12 at 8:55 a.m. and 10:30 p.m. In addition, during the observations on 3/27/12 and 3/28/12, the resident had a heavy growth of facial hair. 4. Resident A was admitted on [DATE] with [DIAGNOSES REDACTED]. Licensed staff coded him/her on the 1/10/12 significant change MDS assessment as cognitively impaired and as needing total assistance with activities of daily living (ADLs). There was not a comprehensive care plan developed to address his/her personal care needs. However, according to the ADL Care Plan in the certified nursing assistants (CNAs) assignment book, mouth care was supposed to have been provided to the resident every shift. On 3/26/2012 at 2:05 PM, the resident was seated in a geri-chair in his/her room. He/She had a foul mouth odor and there was gummy spittle in his/her mouth. The resident's lips were dry and peeling. On 3/27/2012 at 11:34 a.m., the family member of resident A stated that she visited the resident almost daily. She stated that the resident's lips were dry 3-4 times a week. She said that she had noticed a mouth odor as recently as yesterday afternoon when she visited. She said that she had not complained to staff because they should know that the resident needed his/her mouth cleaned and it was just easier to do it herself. She stated that, when she had visited yesterday, she cleaned the resident's mouth herself. On 3/28/12 at 10:10 a.m., the resident was seated in a geri-chair in his/her room. When the resident opened his/her mouth to yawn, his/her tongue was exposed. It had a thick, white coating on it. He/She had a slight mouth odor at that time. On 3/28/12 at 4:45 p.m., CNA AA stated that staff provide oral care for the resident every morning. On 3/29/12 at 11:40 a.m., CNA BB returned the resident to his/her room from the shower. BB stated that she had not provided mouth care yet but, it was provided every day on the 7a.m. to 3p.m. shift. CNA BB stated that the resident sometimes resisted opening his/her mouth for mouth care. At that time, BB was able to open the resident's mouth wide enough to see the white substance on his/her tongue. On 3/29/12 at 12:50 p.m., registered nurse CC assessed the resident's mouth. She stated that it was sometimes difficult to provide mouth care for the resident because he/she resisted opening his/her mouth. However, CC was able to open the resident's mouth wide enough to observe the white substance on the resident's tongue. A review of the clinical record revealed no evidence that the resident resisted mouth care. Certified nursing assistants were not aware of the resident's ADL Care Plan to provide mouth care to the resident every shift. There was no evidence that the facility had monitored the resident's mouth care to evaluate if it was being done every shift and the effectiveness, of the provision of mouth care as scheduled, to meet the resident's needs. 5. Resident #45 was coded on the 1/17/12 quarterly MDS assessment as having cognitive impairments and as needing total assistance for personal hygiene. There was not a plan of care to address his/her personal hygiene needs. During observations on 3/27/12 at 2:35 p.m., 3/8/12 at 8:20 a.m., and on 3/29/12 at 12 p.m., the resident was observed with thick, chin hair. Observations on 3/27/12 at 9 a.m. revealed that the resident had unclean and untrimmed fingernails. On 3/28/12 at 8:20 a.m. and 8:45 a.m., the resident's fingernails were clean but, were long. Review of the ADL Care Plan revealed that nail care was to be done daily and as needed. During an interview on 3/29/12 at 8:45 a.m., CNA YY said that the nurses were responsible for cutting residents' fingernails as needed. During an interview on 3/29/12 at 10:35 a.m., licensed nurse XX stated that CNAs were supposed to clip the residents' nails if they noticed that they needed trimming. She said that the nurses were also responsible for observing and clipping residents' nails if needed. | 2016-07-01 |