cms_GA: 82
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 82 | GLENWOOD HEALTH AND REHABILITATION CENTER | 115025 | 4115 GLENWOOD RD | DECATUR | GA | 30032 | 2018-11-01 | 604 | D | 0 | 1 | GW4111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record reviews, and review of facility policy, the facility failed to ensure that one (1) of 35 sampled residents (R) (R#44) was free from a physical restraint. While R#44 was seated in a high-back wheelchair, the resident's legs were strapped together for approximately three (3) hours, and the resident was unable to move her legs. The findings included: Review of R#44's clinical record revealed the resident was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Review of R#44's Significant Change Minimum Data Set (MDS) assessment dated [DATE] and her Quarterly MDS dated [DATE] revealed the resident was severely cognitively impaired and had no physical behaviors. R#44 required extensive to total assistance for all activities of daily living (ADLs) and utilized a wheelchair for mobility. The resident had no falls during either assessment period. R#44 received no therapy services and no restraints or alarms were used during either assessment period. Review of R#44's ADL care plan dated 11/4/17 noted R#44 had an ADL self-care performance deficit related to (r/t) Alzheimer's and weakness. Goal for R#44 was to maintain current level of function in ADLs thru the review date. Interventions included: Dressing: receives total to extensive assist with one staff support; Bathing/hygiene - she receives shower 3 times per week with total assist from staff. Staff will trim her nails as needed (prn); encourage active participation in tasks; Bed mobility: requires total to extensive assistance by 1- to 2 (1-2) staff to reposition in bed and as necessary; Eating: requires extensive assistance with eating; Transfer: requires total assist by 1-2 staff to move between surfaces; Observe/document/report prn any changes any potential for improvement, reasons for self-care deficit, expected course, declines in function; Praise all efforts at self-care; physical therapy/occupational therapy (PT/OT) evaluation and treatment as per MD (doctors) orders. The care plan did not reference the use of a restraint. Review of R#44's fall care plan dated 11/4/17 revealed the resident was a moderate risk for falls r/t confusion and being unaware of safety needs. Interventions included: Anticipate and meet the resident's needs; Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed; Ensure that the resident is wearing appropriate footwear rubber sole bottoms and describe correct client footwear; Review information on past falls and attempt to determine cause of falls. Record possible root causes. After remove any potential causes if possible. Educate resident/family/caregiver/IDT (Interdisciplinary Team) as to causes; and transfer with mechanical lift with the assistance of two staff. The care plan did not reference the use of a restraint. Review of R#44's OT Discharge Summary dated 6/21/18 noted Patient will demonstrate increase in upright sitting posture for 30 minutes in order to participate in social activities within the unit and for environmental orientation with use of appropriate seating device .wheelchair modification and adaptation including providing a high back recline chair, a saddle wedge cushion to improve posture for social interaction and comfort during meals. Staff education on positioning technique and application and care . Review of R#44's physician's orders [REDACTED].>Review of the Magnolia Assignment Sheet dated 10/31/18 revealed a Certified Nursing Assistant (CNA) was assigned to R#44. Review of the Magnolia Assignment Sheet dated 10/31/18 noted CNA FF was assigned to the resident for the 7:00 a.m. - 3:00 p.m. shift. Observations in R#44's room on 10/29/18 at 12:40 p.m. revealed the resident was in bed and appeared to be sleeping. A high-back wheelchair was sitting next to the resident's bed and a cushion had been placed in the seat of the wheelchair. Observations in the common area day room of Magnolia Hall on 10/31/18 at 10:00 a.m. revealed R#44 was sitting in a high-back wheelchair. R#44 was not seated correctly in the wheelchair and the resident's bottom was sliding forward in the seat of the chair. R#44's feet were positioned on the wheelchair's padded footrests, and the resident's legs were held together directly below the knees with a black strap that buckled in the front of the resident's legs. Interview at this time with R#44's Unit Manager (UM) CC confirmed the strap around the resident's legs was restricting the resident's movement, and R#44 was not able to unbuckle the strap without assistance. UM CC said the strap should not be in place and stated she would get with therapy to find out about the positioning/placement of the strap. When asked about the staff responsible for getting the resident up this morning, UM CC said she'd have to check with the 11 p.m. -7:00 a.m. shift staff because that's who got her up this morning. When asked if the resident had been checked and changed since that time, UM CC said the resident had been and she would determine who was responsible for taking care of the resident during the day shift (today). Observation on 10/31/18 at 10:10 a.m. in the therapy department revealed four (4) therapy staff re-positioned the resident in the wheelchair and discovered that the cushion in the seat of the wheelchair had been placed backwards in the seat. During this observation an interview with Certified Occupational Therapist Assistant (COTA) DD confirmed the strap should not have been buckled around the resident's knees/legs. COTA DD said the cushion in the wheelchair was an anti-thrust cushion used to prevent R#44 from sliding forward in the chair. COTA DD said, when the cushion is placed in the seat of the wheelchair correctly, the strap of the cushion should be buckled underneath the set of the wheelchair. During a follow-up interview at the nurses' station with UM CC on 10/31/18 at 11:35 a.m. UM CC again stated that the 11:00 p.m. - 7:00 a.m. staff assisted the resident in getting up this morning. UM CC stated the 7:00 a.m. - 3:00 p.m. staff who was assigned to R#44 this morning became ill and had to go home early from her shift. UM CC said the 7:00 a.m. - 3:00 p.m. staff did toilet the resident before she went home early due to illness. UM CC said there were no other staff working with the resident on the morning of 10/31/18. Interview on 10/31/18 at 12:45 p.m. in the hallway of Magnolia unit with Licensed Practical Nurse (LPN) EE revealed the nurse was not aware of the staff who was responsible for getting the resident up that morning. Interview on 11/1/18 at 12:00 p.m. with the facility's Director of Nursing (DON) revealed UM CC informed her on 10/31/18 that R#44's legs had been inappropriately and improperly restrained with the seat cushion's straps and buckle. Interview on 11/1/18 at 12:39 p.m. at the nurses' station with Certified Nursing Assistant (CNA) FF revealed she was assigned to R#44 on the morning of 10/31/18; however, the overnight staff had already dressed and gotten R#44 up that morning. CNA FF said she did see the overnight CNA wheel R#44 out to the common area around 7:10 a.m. on the morning of 10/31/18, but CNA FF did not notice that the resident's legs were restrained. CNA FF said she got sick about an hour into her shift and then left for home around 8:00 a.m. The aide said she did not toilet R#44 before leaving the facility on the morning of 10/31/18. CNA FF said she was aware that the strap to the cushion was to be buckled underneath the seat of the wheelchair. Review of the facility's Restraint Management policy revised (MONTH) (YEAR) noted: Restraints are implemented in accordance with State and Federal regulations. If indicated, the least restrictive restraint is used for the least amount of time. Restraints are not used as a disciplinary action or for the convenience of the facility to control behavior .Definitions - Physical Restraint is any manual method, physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or normal access to one's body .Examples of Physical Restraints - Physical restraints include, but are not limited to, leg restraints, hand mitts, soft ties, lap cushions, and lap trays the resident cannot remove easily. The reason for the restraint must be documented in the resident's plan of care. | 2020-09-01 |