cms_GA: 1251

In collaboration with The Seattle Times, Big Local News is providing full-text nursing home deficiencies from Centers for Medicare & Medicaid Services (CMS). These files contain the full narrative details of each nursing home deficiency cited regulators. The files include deficiencies from Standard Surveys (routine inspections) and from Complaint Surveys. Complete data begins January 2011 (although some earlier inspections do show up). Individual states are provides as CSV files. A very large (4.5GB) national file is also provided as a zipped archive. New data will be updated on a monthly basis. For additional documentation, please see the README.

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rowid facility_name facility_id address city state zip inspection_date deficiency_tag scope_severity complaint standard eventid inspection_text filedate
1251 PRUITTHEALTH - EASTSIDE 115391 2795 FINNEY CIRCLE MACON GA 31217 2018-08-17 580 J 1 0 RM0M11 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews and record review, the facility failed to notify the physician and responsible party in a timely manner, of a change in condition for one resident (A) from a total sample of 19 residents. An Abbreviated/Partial Extended Survey investigating complaint GA# 560 was initiated on [DATE] and concluded on [DATE]. The complaint was substantiated with deficiencies. On [DATE], a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause, serious injury, harm, impairment or death to residents. The facility's Administrator and Director of Health Services (DHS) were informed of the Immediate Jeopardy on [DATE] at 3:30 p.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on [DATE]. The Immediate Jeopardy continued through [DATE] and was removed on [DATE]. The facility implemented a Credible Allegation of Compliance related to the Immediate Jeopardy on [DATE]. The immediate jeopardy is outline as follows: Resident (R) A had not executed an Advance Directive. R A experienced a change in condition on [DATE], becoming unresponsive while staff attempted to assist the resident out of the bathroom, after he had sustained an unwitnessed fall. Cardiopulmonary resuscitation (CPR) was initiated by certified nursing staff, and Emergency Medical Services (EMS) were notified. However, the resident's advance directive status was inaccurately assessed by licensed nursing staff as Do Not Resuscitate (DNR) and CPR was stopped, prior to the arrival of EMS services and in absence of physician's orders [REDACTED]. The inaccurate Advance Directive status of DNR was obtained by licensed nursing staff from an incorrectly labeled form included in the Medication Administration Record (MAR) book. The DHS pronounced the resident's death at the facility on [DATE] at 7:09 a.m. at which time she notified the physician and family. The DHS was not aware the resident's Advanced Directive status was inaccurate until notified by the family later in the morning of [DATE]. Immediate Jeopardy was identified on [DATE] and determined to exist on [DATE] in the areas of 42 CFR 483.10 Resident Rights, F580; 42 CFR 483.21 Comprehensive Resident Centered Care Plans, F656; 42 CFR 483.24 Quality of Life, F678; 42 CFR 483.35 Nursing Services, F726; 42 CFR 483.70 Administration, F835; and 42 CFR 483.75 Quality Assurance and Performance Improvement (QAPI), F868, all at a Scope and Severity (S/S) of a [NAME] Additionally, Substandard Quality of Care was identified at 42 CFR 483.24 Quality of Life, F678. A Credible Allegation of Compliance was received on [DATE]. Based on observations, record reviews, interviews and review of the facility's policies as outlined in the Credible Allegation of Compliance, it was validated that the corrective plans and the immediacy of the deficient practice was removed on [DATE]. The facility remained out of compliance at a lower scope and severity of D while the facility continued management level staff oversight of the Advance Directive system and continued education. This oversight process included the analysis of facility staff's conformance with the facility's Policies and Procedures governing the accurate acquiring of the necessary steps to ensure the continuity of care. In-service materials, policies and records were reviewed. Observation, record review and interviews were conducted with staff to ensure they demonstrated knowledge of facility Policies and Procedures. Findings include: The facility had a Change in Condition policy: When to report to the MD/NP/PA guidance. The form documented that immediate notification should be made of any symptom, sign or apparent discomfort that is acute or sudden in onset and is a marked change in relation to usual symptoms and signs or is unrelieved by measures already prescribed. Resident (R) A was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. A review of the Advance Directives Checklist form, dated [DATE], revealed that the resident had not executed an Advance Directive and did not wish to discuss Advance Directives further at that time. The resident had a physician's orders [REDACTED]. R A was care planned for being at risk for falls, use of a wheelchair for mobility and able to ambulate short distances. A care plan was also in place, dated [DATE], for being at risk for respiratory complications. The care plan problem included that the resident would adjust his own oxygen setting and refuse to wear oxygen at times. R A experienced a change in condition on [DATE]. Review of a Nurse's Note, dated [DATE] at 5:15 a.m., documented that a Certified Nursing Assistant (CNA) reported that the resident complained of shortness of breath and was sitting on the commode in the bathroom, not wearing his oxygen. The CNA applied the resident's oxygen nasal cannula and the resident returned to bed. The note further documented that the CNA reported that the resident returned to the bathroom and pressed the call light again. The resident again complained of shortness of breath and was not wearing his oxygen. The note continued to document that the CNA replaced his oxygen and exited the bathroom. A subsequent Nurse's Note on [DATE] at 5:20 a.m., documented that the resident was observed on the floor, in the bathroom, between the commode and the wall. The resident stated he could not get up. The note further documented that the resident was moved, by staff, from between the wall and commode and into his room and became unresponsive. The note continued to document that CPR was initiated and an oxygen saturation level and carotid pulse were unable to be obtained. At 5:30 a.m., 911 was notified and an ambulance dispatched while CPR continued to be performed. A 5:40 a.m. Nurse Note entry documented that a MAR record review indicated that the resident was a DNR and CPR was discontinued at that time. At 5:45 a.m., the DHS was notified that R A had expired and at 5:50 a.m., EMS personnel arrived and were notified that the resident was a DNR, therefore they left the facility. Nurse's note entry document that the DHS arrived and pronounced the resident as deceased at 7:09 a.m., notified the physician at 7:15 a.m., and the resident's responsible party at 7:20 a.m. The DNR status that was documented on the MAR record, referenced in the [DATE] at 5:40 a.m. nurse's note entry, was not accurate and was not consistent with the Advance Directives Checklist form that documented that the resident had not executed an Advance Directive. A review of the facility investigation, initiated on [DATE], revealed that the DNR list that was included at the front of the MAR book had been incorrectly labeled by the former Social Service Director (SSD). During an interview on [DATE] at 11:08 a.m., the former SSD, who came into the facility for the interview, confirmed that the DNR list was an error and should have been labeled as the behavior management list. Review of the form used on [DATE] by Licensed Nursing Staff, revealed DNR dated [DATE] with two residents listed, including R [NAME] There was no evidence that licensed nursing staff notified the physician or responsible party timely, of the resident's sudden change in condition, notification of EMS personnel, and initiation and cessation of CPR prior to EMS arrival and departure. During interviews on [DATE] at 1:45 p.m. and [DATE] at 12:46 p.m., the DHS confirmed that she notified the physician and R A's responsible party of his death, after she arrived at the facility. She further stated that when she notified them of the resident's death, she was unaware of the events that had occurred because they had not been reported to her. She stated that she did not become aware of the events that had occurred until Licensed Practical Nurse (LPN) UU entered the 9:30 a.m. morning meeting, on [DATE], and notified all staff, that were present, that R A's family member had called the facility stating the resident was a full code and inquiring about EMS. During an interview on [DATE] at 11:47 a.m., with the physician, he stated that licensed nursing staff did not call him when he would have expected them to call him, which is when the resident's condition is changing. He stated that the call from the DHS was the first call he received regarding R [NAME] Cross reference to F678 A facility investigation was initiated on [DATE] and the following concerns were identified and evidenced through review of Nurse Consultant email dated [DATE] stating Eastside will proceed with a self-imposed jeopardy for the following: 1. Failure to notify the resident's responsible party of a change in condition timely. 2. Failure to continue CPR once started, without a stop order from the physician. 3. Failure to have accurate DNR lists in the front of the MAR. The facility implemented the following actions to address their identified concerns: 1. A complete audit of all residents' charts to confirm the accurate advance directive status. The audit will include physician's orders [REDACTED]. The Advance Directive facility checklist will be used to record the audit. New admissions will have their Advance Directive status verified and documented on admission. New admissions will be verified for accuracy by the DHS or Clinical Care Coordinator (CCC). New admissions will be added to the audit tool and continued until substantial compliance is maintained for three months. Issues identified as a result of the audits will be corrected immediately. 2. Education provided to the Social Worker (SSD) related to the importance of accuracy of Advance Directive status and completeness of all required paperwork including the list of DNR's in front of the MAR. 3. Education to Registered Nurses (RN) that will be on-call to pronounce, that will include coming to the facility immediately even if they are told the resident was a DNR. 4. Education to nurses regarding once CPR is started (even if in error), it cannot be stopped unless a physician orders [REDACTED]. When looking to confirm an Advance Directive status during an emergency, the chart must be opened and reviewed; looking for Advance Directive paperwork and an order on the POF. Never rely on the list in front of the MAR. 5. These audits and education pieces will be brought to daily stand-up meetings and reviewed by the Administrator. Results will be brought to QAPI monthly for three months or until substantial compliance is obtained for three months. Review of the facility's implementation of action related to the self-imposed jeopardy that record review revealed the actions were incomplete, and that residents were still at risk including: Care plans did not accurately reflect Advanced Directives, the survey team identified a resident who had no Advance Directive Sheet in their record and that only Licensed Nurses had been educated. An interview on [DATE] at 3:30 p.m. with the Administrator and the DHS revealed that the facility Policy and procedure titled Do Not Resuscitate Policy had not been reviewed or updated as of [DATE]. Therefore, this action did not remove the IJ related to accuracy or documentation of Advance Directives. The facility implemented the following actions to remove the Immediate Jeopardy related to notification: The facility failed to notify the physician upon change of condition for Resident [NAME] The facility failed to notify the MD at the time of the incident because the LPN incorrectly identified that the resident was a DNR. The system that failed was the DNR system, The Social Worker (SSD) provided a DNR listing that was not accurate and the LPN failed to verify the code status in the resident chart. Although the DNR listing was found to be incorrect, the LPN failed to notify the MD at the time that Resident A had a change of condition. This Immediate Jeopardy was abated on [DATE], at which time the facility completed the following actions: 1. The CCC and DHS were educated by the SNC on [DATE] on MD notification policy for change of condition. CCC and DHS educated active licensed staff of MD notification policy for change of condition on [DATE] and [DATE]. ,[DATE] LPNs have received education as of [DATE] (92%), ,[DATE] RNs completed as of [DATE] (87.5%). 2. Certified staff were educated on [DATE] to report change of condition to Nurse by the Administrator and DHS. ,[DATE] active CNAs completed education as of [DATE] (85%). 3. All newly hired licensed and certified staff will be educated on this policy upon orientation. Licensed and certified staff who have not received this education, due to scheduled vacation, FMLA or PRN (as needed) status will not work until education is completed. 4. 24 hr reports will be reviewed daily x2 weeks by the DHS or Registered Nurse (RN) on call for change of condition to ensure MD notification conducted as required. Findings will be reported by the DHS in the QAPI meeting monthly x3 months. The State Survey Agency (SSA) validated the corrective actions taken by the facility as of [DATE] as follows: 1. An interview with the CCC on [DATE] at 12:01 p.m. and the DHS on [DATE] at 1:45 p.m. revealed that both had been educated by the SNC regarding MD notification policy for change of condition on [DATE] and on [DATE]. Review of the sign in sheets confirm the in-services. Verification of sign in sheets for Licensed Nurses confirmed that on [DATE], 20 licensed nursed had completed the in-service on Change of Condition with one nurse on [DATE]. 2. Review of the CNA sign-in sheets on Notification of Change revealed that on [DATE] and [DATE] that 30 of 34 CNA's had been in-serviced. 3. A interview with the CCC on [DATE] at 1:20 p.m. revealed the facility had one new hire, who was educated on [DATE]. Any staff returning to work or new hire must have the in-services prior to working with residents. 4. Review of the 24-hour report revealed these are reviewed by the DHS and signed as reviewed by the DHS. Interviews were conducted with Licensed Practical Nurses (LPN) and Registered Nurses (RN) on [DATE] at 2:15 p.m. with LPN TT and LPN BB, [DATE] at 2:25 p.m. with LPN EEE and LPN UU, [DATE] at 3:45 p.m. with RN FF and LPN KK, [DATE] at 4:00 p.m. with LPN HH, [DATE] at 11:18 a.m. with LPN MM and on [DATE] at 11:30 a.m. with LPN LLL, the Minimum Data Set (MDS) Coordinator revealed they had all be recently in-serviced on the policy and procedure for notifying the physician if a change in condition should occur, their role in the notification process in a timely manner. Interviews were conducted with Certified Nursing Assistants (CNA) on [DATE] at 2:04 p.m. with CNA XX and CNA ZZ, [DATE] at 2:10 p.m. with CNA GG and CNA VV, [DATE] at 2:35 p.m. with CNA DD and CNA YY, [DATE] at 2:39 p.m. with CNA WW and CNA II, [DATE] at 3:35 p.m. with CNA DDD, [DATE] at 3:40 p.m. with CNA JJ and CNA CCC, [DATE] at 4:00 p.m. with CNA BBB, and [DATE] at 4:05 p.m. with CNA AAA revealed that they had participated in an in-service which included notification and their role in this process. 2020-09-01