cms_TN: 76
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 76 | NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE | 445033 | 1414 COUNTY HOSPITAL RD | NASHVILLE | TN | 37218 | 2017-06-13 | 279 | D | 0 | 1 | PJSZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to revise the care plan for side rails and bed alarm for 3 of 23 (Resident #25, 54, and 62) residents reviewed of the 43 resident 's included in the Stage 2 review. The findings included: 1. Medical record review revealed Resident #25 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed he had a severe cognitive deficit. Review of physician orders [REDACTED]. Review of the fall plan of care with an initiation date of 7/15/16 revealed the resident was identified as at risk for injury. The fall plan of care and the activities of daily living plan of care did not include the use of the side rails as ordered by the resident's physician. Observations in Resident #25's room on 6/11/17 at 2:48 PM, revealed Resident #25 lying in bed with bilateral full side rails in the raised position. Licensed Practical Nurse (LPN) #2 verified Resident #25 was only supposed to have the full side rail on the left side of the bed to assist with positioning and he was capable of sitting up on the side of the bed on his own. On 6/14/17 at 12:10 PM, LPN #1 verified the plan of care did not include the use of the side rail. 2. Medical record review revealed Resident #54 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #54's most recent quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #54 had severe cognitive deficits. The Fall Risk Evaluation dated 4/10/17 had a score of 12 indicating the resident was at risk for falls (a score of 10 or higher indicated the resident is at risk.) Review of the physician's orders [REDACTED].#54 had an order for [REDACTED].>The plan of care for falls dated 8/16/16 indicated that the resident was at risk for falls as determined by a score of 18 on the 7/19/16 fall risk screen. The goal was for the resident to not sustain a fall related injury by utilizing fall precautions through the next review date of 7/11/17. The plan of care did not address the use of the physician ordered bed alarm. On 6/14/17 at 12:30 PM, LPN #1 verified the plan of care did not include the use of the physician ordered bed alarm. 3. Medical record review revealed Resident #62 was last admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #62's last quarterly MDS assessment dated [DATE] indicated the Resident #62 had severe cognitive deficits. The current fall plan of care listed bilateral side rails as enabler's but did not include the type of side rails (namely full, half or quarter side rails). Resident #62 was observed in bed with bilateral full side rails up on both sides of the bed on 6/11/17 at 4:20 PM; on 6/12/17 at 3:39 PM and 3:53 PM; on 6/13/17 at 7:40 AM, 8:41 AM, and at 1:39 PM; and on 6/14/17 at 9:36 AM. During the observation on 6/12/17 at 3:39 PM, LPN #4 verified the resident always used full side rails when the resident was in bed. Interview with LPN #1 on 6/14/17 at 12:20 PM, LPN #1 stated Resident #62 was not cognitively capable of using the side rails as enabler's and stated the bilateral full side rails were put into place at the request of the resident's family. | 2020-09-01 |