cms_AL: 54
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 54 | ATHENS HEALTH AND REHABILITATION LLC | 15016 | 611 WEST MARKET STREET | ATHENS | AL | 35611 | 2019-08-29 | 580 | D | 1 | 1 | 39OM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, record review and review of a facility policy titled, Change in Medical Condition of Resident/Guest(s), the facility failed to ensure Resident Identifier (RI) #272's family/responsible party was notified of a new order written on 4/19/19, for [MEDICATION NAME] DR (Delayed Release) 125 MG (milligrams) sprinkle by mouth at hour of sleep. This deficient practice affected RI #272, one of 25 sampled residents. Finding Include: A facility policy title: Change in Medical Condition of Resident/Guest (s), with an effective date of 11/28/2016 revealed the following: .STANDARD: Notification . legal representative, or interested family member, should occur promptly, according to federal regulations, when there is a change in the resident/guest (s) condition, . *A need to alter treatment . to commence a new form of treatment . RI #272 was admitted on [DATE] with [DIAGNOSES REDACTED]. A review of RI #272 Physician order [REDACTED]. The orders also included an order for [REDACTED]. On 8/29/19 5:52 p.m., the surveyor conducted an interview with Employee Identifier (EI) #3, Registered Nurse Unit Manager/Supervisor. The surveyor asked EI #3 was there an order for [REDACTED].#3 how could she verify that an order had been given. EI #3 stated what she had been told by this company was that you do not have to have a written order, you can put verbal orders directly into the computer. The surveyor asked EI #3 when did the physician write the order. EI #3 stated she did not know why the physician did not hand write the order. The surveyor asked EI #3 was this a usual practice. EI #3 stated, not generally. The surveyor asked was the family/responsible party notified of the new order. EI #3 stated it did not look like they were notified. The surveyor asked EI #3 where would the evident be that family was notified if there were evident. EI #3 stated in the nurses notes. The surveyor asked EI #3 was there evident in the nurses notes. EI #3 stated there was no record of it. The surveyor asked EI #3 who would have been responsible for notifying the family. EI #3 stated the nurse that put the order in. The surveyor asked did RI #272 receive [MEDICATION NAME] the entire time he/she was at the facility. EI #3 stated yes, it looked like he/she got it because they (nursing) were signing off that he/she got it. The surveyor asked EI #3 was there a new order for additional [MEDICATION NAME] 20 MG to be given on 4/24/19 for three days. EI #3 stated yes, give [MEDICATION NAME] 20 MG tablet by mouth at noon daily times three days in addition to morning dose. The surveyor asked EI #3 why was there a new order for the additional [MEDICATION NAME] 20 MG on 4/24/19 to be given one everyday at noon for three days. EI #3 stated she did not know, she guest the resident had some [MEDICAL CONDITION]. The surveyor asked EI #3 where would there be evident that the family was notified of that new order. EI #3 stated the LPN (License Practical Nurse) that took the order off should have notified the family. The surveyor asked EI #3 where did she note it in her notes. The surveyor gave EI #3 a copy of the nurse's notes. EI #3 stated it did not look like there was a note. This citation is written as a result of the investigation of complaint/report #AL 292. | 2020-09-01 |