cms_AL: 65
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 65 | MERRY WOOD LODGE | 15019 | P O BOX 130 | ELMORE | AL | 36025 | 2020-03-03 | 580 | D | 1 | 1 | LZCS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, record review and review of a facility policy titled Change in Condition: Notification of the facility failed to contact Resident Identifier (RI) # 24's resident representative when his/her diet was changed to pureed in August 2019. This affected 1 of 20 sampled residents. Findings Include: A review of policy titled Change in Condition: Notification of, with an effective date of 11/28/16, documented: .A Center must immediately inform the patient's Health Care Decision Maker (HCDM) where there is:.A need to alter treatment significantly (that is, a need to discontinue or change an existing form of treatment due to adverse consequences, or to commence a new form of treatment. RI # 24 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI # 24 also had a [DIAGNOSES REDACTED]. A review of RI # 24's diet orders documented the following: 8/13/19.Resident's diet downgraded to pureed due to coughing when eating. Resident appearing at times to have trouble swallowing regular tray. Speech Therapy (ST) was alerted and to see resident. On 03/02/20 at 2:53 p.m. the Surveyor reviewed RI # 24's medical record. A Speech Therapy Initial Evaluation for therapy dates 8/2/19 through 8/31/19 documented the following: . Patient/Caregiver Education = Family/caregiver expressed understanding of evaluation and agreement with goals and treatment plan; Does patient/family agree w/ (with) Diet Recommendation? = Yes. On 3/2/20 at 9:38 a.m. an interview was completed with Employee Identifier (EI) # 3, Speech Therapist. EI # 3 stated she had RI # 24 on her case load on and off in 2019 for swallowing and cognitive problems. EI # 3 was asked what type of diet she recommended for RI # 24. EI # 3 stated she recommended a pureed diet in August of 2019 and RI #24 received that diet after the recommendation. A follow-up telephone interview was completed with EI # 3, Speech Therapist, on 3/2/20 at 2:47 p.m. EI # 3 was asked if she contacted RI # 24's family when he/she went on pureed diet in August. EI # 3 stated no. EI # 3 further stated she had a conversation with RI # 24's daughter but did not call her about the diet change. EI # 3 was asked what the statement on the Speech Therapy Initial Evaluation for therapy dates 8/2/19 through 8/31/19 meant when it documented the Family/Caregiver expressed understanding of the evaluation and agreement with goals and treatment plan to include the diet recommendation. EI # 3 stated it meant she spoke with the facility about the resident's diet, not the family. EI # 3 was asked if she normally called family regarding a diet change. EI # 3 stated no. An interview was completed with EI # 4, Registered Nurse (RN), on 3/3/20 at 9:35 a.m. EI # 4 was asked if nursing staff called RI # 24's daughter when his/her diet was downgraded in August of 2019. EI # 4 stated there was a note about downgrading the diet on 8/13/19, but it was not documented the daughter was called and informed. EI # 4 further stated it should be documented. EI # 4 was asked what was the potential negative outcome of not notifying family of changes. EI # 4 stated the family not knowing about the change. | 2020-09-01 |