cms_GA: 98
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 98 | CENTER FOR ADVANCED REHAB AT PARKSIDE, THE | 115040 | 110 PARK CITY ROAD | ROSSVILLE | GA | 30741 | 2018-08-23 | 689 | D | 1 | 1 | 07R411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review, resident and staff interview, the facility failed to evaluate the risk of leaving one resident (R) (R#25) unattended while sitting on the side of the bed, resulting in a fall from the bed. The sample size was 34 residents. Findings include: Review of R#25's clinical record revealed that she had [DIAGNOSES REDACTED]. Review of R#25's Modification of Annual Minimum Data Set ((MDS) dated [DATE] revealed that she had a Brief Interview for Mental Status (BIMS) score of 9 (a BIMS score of 8 to 12 indicates moderate cognitive impairment); she needed extensive assistance of two or more persons for transfers; was not steady, only able to stabilize with staff assistance for surface to surface transfer; had functional limitation in range of motion on one side of upper and lower extremities; and had one fall with no injury since prior MDS assessment. During interview with R#25 on 8/20/18 at 4:24 p.m., she stated that she had a fall today when staff was in the room with her. She further stated that she fell off the side of the bed onto the fall mat, and that the staff tried but were unable to catch her from falling. Observation at this time revealed that R#25 was in a bed lowered to the floor with an alarm, a bed rail up on both sides of the mattress, and she had a brace on her left leg. During interview with R#25 on 8/21/18 at 8:38 a.m., she stated that when she was receiving therapy in her room yesterday, the therapist sat her up on the side of the bed and then turned around, and she fell off the bed. During further interview, R#25 stated that she had left arm, back and right-sided facial pain after this fall. Review of incident reports revealed that R#25 had a fall from the wheelchair during a staff transfer on 11/25/17; unwitnessed falls from bed on 2/1/18, 3/30/18, and 6/26/18; and a fall from the bed during therapy on 8/20/18. During an observation of a transfer by Certified Nursing Assistants (CNA) CC and DD on 8/22/18 at 7:25 a.m., the tops of R#25's knees were both noted to be reddened and have skin tears. During interview with CNA CC at this time, she stated that R#25 had a fall on Monday (8/20/18), and she thought it was from that. R#25's left arm and leg were observed to be paralyzed, and she was not able to use them to assist with the transfer. Continued observation revealed that the CNAs placed a gait belt around R#25's waist after sitting her up on the side of the bed, and when CNA CC turned around to prepare the wheelchair and CNA DD did not have a firm grasp on the gait belt, the resident started to drift backwards on the bed before being caught supported by CNA DD. During interview with Physical Therapist Assistant (PT-A) EE on 8/22/18 at 12:43 p.m., she stated that she had heard that R#25 had a fall recently when a therapist was working with her, and that she was sitting on the side of the bed and was left unattended. During interview with Occupational Therapist-Registered (OT-R) FF on 8/22/18 at 1:03 p.m., she stated that on 8/20/18 she was working with R#25 on transfers, range of motion to her left arm and neck, and postural control. She further stated that she sat the resident up on the side of the bed, and that the resident's sitting balance on the side of the bed was fair. She stated during continued interview that she got up to move R#25's wheelchair closer to her, which was about two feet away, and had to go around the back of the wheelchair to unlock it. She further stated that she saw from her peripheral vision that the resident was falling, but was not able to get around the wheelchair and back to her before she fell . She stated during continued interview that the resident's whole body fell on to the fall mat at one time, as she had no protective reflexes from the stroke, and the only thing she complained of was that her head hurt just a little bit. During interview with the Physical Therapy (PT) Rehab Director on 8/22/18 at 1:16 p.m., he stated that R#25 had been assessed by PT and OT as Mod/3 for bed mobility supine to sitting, which meant one-person assist. He stated during further interview that one-person transfer assist would have been sufficient, but that he would have had the wheelchair positioned closer to R#25 and would have let go of the resident when she was sitting up. Review of an Occupational Therapy Treatment Encounter Note(s) for R#25 dated 8/20/18 revealed: This OT positioned this pt (patient) EOB (edge of bed) with pt demonstrating F- (fair minus) balance utilizing RUE (right upper extremity) to maintain balance, OT went to position w/c (wheelchair) to bed in preparation for t/f (transfer). Pt lost balance to left and fell from bed onto floor mat on floor beside bed. | 2020-09-01 |