cms_TN: 3392
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 3392 | NASHVILLE CENTER FOR REHABILITATION AND HEALING LL | 445512 | 832 WEDGEWOOD AVENUE | NASHVILLE | TN | 37203 | 2019-11-26 | 580 | D | 1 | 0 | 133K11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review and interview, the facility failed to notify the resident representative of 2 room changes for 1 resident (#2) of 4 residents reviewed with room changes. The findings included: Review of the facility policy, Transfer-Room to Room, revised on 10/2012, revealed .That his or her family and visitors will be informed of the room change .Documentation-The following information should be in the resident's medical record .the date and time the room transfer was made . Review of the facility policy, Transfers or Discharge Documentation, revised 8/2014, revealed .When a resident is transferred or discharged , the reason for the transfer or discharge will be documented in the medical record .Documentation .concerning all transfers or discharges must include .The reason for the transfer or discharge .That the appropriate notice was provided to the resident and/or representative .The date and time of the transfer or discharge . Medical record review revealed Resident #2 was admitted to the facility on [DATE]. On 12/12/17 he was discharged to the hospital for elevated blood sugar and readmitted to the facility on [DATE]. On 12/26/17 he was discharged to the hospital for having pulled out the tube feeding tubing and was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum (MDS) data set [DATE] revealed Resident #2 was severely cognitively impaired with a score of zero (0) on the Brief Interview for Mental Status (BIMS) and required extensive or total 2 person assistance for all activities of daily living Medical record review of the room location for Resident #2 revealed from 6/30/17 through 2/1/18 he was in room [ROOM NUMBER] B. On 8/8/19 he was moved to private room [ROOM NUMBER]. On 8/13/19 he was relocated to room [ROOM NUMBER] [NAME] On 8/16/19 he remained in the same room but changed bed location to 510 B where he currently resides. Medical record review of the Nurse Practitioner (NP) #2's progress note dated 8/8/19 revealed Resident #2 had [MEDICAL CONDITION]/blisters on the right lateral torso and a single blister on the right lateral thigh. The NP plan was to start isolation precautions for possible [MEDICAL CONDITION]. Medical record review of NP #1's progress note dated 8/9/19 revealed Resident #2 had raised [MEDICAL CONDITION], mild [DIAGNOSES REDACTED] (redness of skin) in diaper area to abdomen and upper thigh. The plan was .irritant [MEDICAL CONDITION]-rash appears to be in diaper area. Start [MEDICATION NAME] with zinc (steroid/antifungal medication with mineral supplement for healing) every day for 10 days and follow-up . Medical record review of the Medication Review Report dated 8/2019 revealed on 8/10/19 [MEDICATION NAME] cream mixed with zinc to be applied to abdomen and upper legs every day for 10 days had been ordered. Medical record review of the 8/2019 Medication Administration Record [REDACTED]. Medical record review of the Nursing Progress Note dated 8/9/19 revealed .Late Entry .Resident's daughter at desk inquiring why her father was moved, nurse informed her he needed a private room until he was evaluated for shingles. Daughter stated family was not notified, (named Licensed Practical Nurse #1/Unit Manager) was notified and informed daughter she thought nurse had called the family and she would investigate and take care of it on Monday . Medical record review of NP #2's progress note dated 8/12/19 revealed Resident #2 had no rash visible. Review of the facility census revealed from 8/8/19 through 8/11/19 there were 117 residents. The facility was licensed for 119 bed capacity. Interview with Registered Nurse (RN) #1 and the Administrator on 11/18/19 at 4:50 PM in the conference room revealed on 8/8/19 NP #2 had assessed Resident #2 as possibly having shingles and the resident was placed in a private room, 412. The following day, 8/9/19, NP #1 assessed the resident and determined it wasn't shingles. By that time the room the resident had vacated on 8/8/19 had been occupied by another resident so the resident went next door (510) but he had the hallway bed not the window bed like he had before. Further interview revealed when the window bed became available, the next day, he was relocated to the B bed. Further interview revealed the Social Worker (SW) was responsible to notify the resident's representative of the room changes. Interview with the SW on 11/20/19 at 10:29 AM in her office revealed the SW was responsible to inform the resident's representative of any room changes. Further interview confirmed she failed to notify Resident #2's representative of the room changes on 8/8/19 and on 8/13/19. | 2020-09-01 |