cms_GA: 2026
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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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 2026 | ORCHARD HEALTH AND REHABILITATION | 115522 | 1321 PULASKI SCHOOL ROAD | PULASKI | GA | 30451 | 2017-10-08 | 490 | J | 1 | 0 | UU0Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews and record review, the facility failed to maintain an effective Quality Assurance (QA) program that systematically reviewed the residents and the physical environment for elopement risks. The sample size was 6 residents. 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, Director of Nursing (DON), and the Regional Vice President (RVP) were informed of the immediate jeopardy on [DATE] at 6:45 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 outlined as follows: Resident #1 (R#1) was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Annual Minimum Data Set (MDS) assessment dated [DATE], revealed that the resident had a Brief Interview for Mental Status (BIMs) score of 6 indicating that the resident was severely cognitively impaired. The resident's functional status was documented that the resident's locomotion (walking) on the unit required supervision meaning oversight encouragement or cueing. Record review revealed that on [DATE], R#1 eloped from this facility and walked about one mile down the highway. The resident was found by staff and returned to the facility. Further record review revealed that after the resident eloped on [DATE], that the facility failed to update the resident's care plan and failed to put new care plan interventions in place to prevent the resident from eloping from the facility again. On [DATE], R#1 eloped from the facility between the hours of 10:30 a.m. and 1:30 p.m. The resident was last seen in the morning exercise class scheduled on [DATE] from 10:00 a.m. to 10:30 a.m. The facility realized that the resident was missing at approximately 1:10 p.m. when the kitchen staff observed that the resident's lunch tray was still on the serving cart. The resident's family, physician, and police were notified. Foot patrols were begun by the Sheriff's office and nursing home volunteers. Additional searches were conducted until [DATE], at approximately 1:30 p.m. when R#1 was found approximately 1/4 of a mile from the facility, deceased . The immediate jeopardy was related to the facility's noncompliance with the program requirements at F 278 SS=J 483.20(g)-(j) Assessment Accuracy/Coordination/Certified, F280 S/S: J 483.10(c)(2)(i-ii,iv,v)(3),483.21(b)(2) Right to participate in planning care - Revise care plan, F 323 SS=J 483.25(d)(1)(2)(n)(1)-(3) Free of Accident Hazards/Supervision/Devises F 490 SS=J 483.70 Effective Administration/Resident well-being. Additionally, Substandard Quality of Care was identified with the requirements at F 323 SS=J 483.25(d) (1) (2) (n) (1)-(3) Free of Accident Hazards/Supervision/Devices. 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 were 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 resident assessments related to elopement, updating and revising care plans, systematic review of residents and the physical environment for elopement risks. In-service materials and records were reviewed and records were reviewed. Observation and interviews were conducted with staff to ensure they demonstrated knowledge of facility Policies and Procedures. Resident records were reviewed to ensure that resident care and treatment, including assessments and care plans were current and accurate. The IJ was removed on [DATE]. Findings include: Observations, clinical records review, and staff interviews revealed that the facility was not in substantial compliance during the Abbreviated Extended Survey conducted [DATE] through [DATE]. Refer to the following deficiencies for specific details of the noncompliance. Cross reference to F278: Based on interviews and record review, the facility failed to accurately assess one resident (R) #1, as high-risk for elopement on admission (resident had a known history of elopement and attempted elopement) resulting in the resident successfully eloping on [DATE]. The facility failed to re-assess the resident and his elopement risk after his return. Cross reference to F280: Based on observation and interview, the facility failed to review and revise the care plan, assess the resident's responses to current care plan interventions and failed to get input from the resident or his/her representative to assess the reason for the elopement and develop new interventions to prevent future elopement attempts for one resident (R) #1. Cross reference to F323: Based on interviews and record review, the facility failed to provide a secure environment for one resident (R) #1 of six residents sampled with a known history of elopement and elopement attempts. After a successful elopement from the facility on [DATE], the facility failed to address the resident's risks after the elopement, failed to assess for and evaluate those risks, and failed to implement interventions to reduce those risks. R#1 was able to successfully elope a second time and was found, deceased , four days after the elopement. Interview with the Administrator and the Regional Vice-President on [DATE] at 10:45 a.m. revealed that R#1's [DATE] elopement was discussed during the scheduled Quality Assurance and Performance Improvement (QAPI) meeting on [DATE] at 12:00 p.m. and no changes were recommended to R#1's plan of care. Post survey interview with the DON on [DATE] at 11:48 a.m. revealed that Facility does not believe any other interventions were necessary, no changes were made, so nothing was required follow-up. Residents were not assessed or re-assessed for elopement risks and no care plan revisions were made for R#1 related to elopement or elopement risk after R#1 eloped in (YEAR). The facility implemented the following actions to remove the Immediate Jeopardy 1. On [DATE] at 1:45 pm the Administrator initiated the Emergency Preparedness Missing person plan after being informed that staff could not locate patient R#1. The Administrator assumed the Incident Commander role and organized search teams to search the center, surrounding outside area and local areas surrounding the center. The Administrator directed the Director of Nursing and Assistant Director of Nursing to visually account for all residents in the center and all residents were accounted for. The Administrator directed the Maintenance Director to check all exit doors and gates to ensure that they were closed and locked. The Administrator directed the Regional Nurse to assist the Director of Nursing, Assistant Director of Nursing, and three Resident Care Coordinators to re-assess all residents for Elopement Risk. All residents were assessed for elopement risk and grouped according to high, medium and low risk status. All care plans have been reviewed and revised, if indicated, for all high and medium risk elopment status. 2. On [DATE] at 2:00 p.m. the Administrator notified the Candler County Sheriff's Office. The Sheriff's Office was on site at 2:15 p.m. and assumed the Incident Commander role and began to lead an extensive search for the patient that included: - A three-mile radius ground search using trained medical staff, law enforcement agents, K-9s. - A five to seven-mile radius air search using drones, two planes and a Helicopter with infrared capability. - Facility Staff placed calls and provided search description and pictures of R#1n to local emergency room s on Friday and Saturday; confirmed by RVP. - Facility Staff and volunteers searched on foot and car in surrounding areas; Confirmed by RVP, everyone was participating. - Facility staff and volunteers distributed flyers to private homes in area and local/surrounding businesses. - Flyers were faxed to local and surrounding emergency room s, Fire Departments, EMS and Private Ambulance/Transport Companies. ([DATE], [DATE] and [DATE] done by Human Resource Associate and patient transition directors) 3. On [DATE], the Administrator contacted R#1 physician and family. The Administrator provided contact information and updated status on law enforcement investigation. 4. On [DATE], the Administrator posted staff members at the exit door that was suspected that the resident exited until an audible alarm was placed on the door at approximately 5:00 p.m. Education provided included: In the instance that the alarm goes off, an employee is to get with another employee (go in pairs) and make rounds outside of the building, once inside the building, every patient is to be accounted for. Remaining staff members were educated on [DATE] by Administrator and Director of Nursing. 5. On [DATE], the Administrator called and Ad-hoc (imppromptu) QAPI meeting with the Director of Nursing, Assistant Director of Nursing, Financial Controller, MDS Coordinator, Food Service Manager, Social Services Director, Resident Care Coordinator, Maintenance Director, Environmental Services Supervisor, Human Resource Manager, Recreational Therapist, Regional Engineering and Safety Manager, Regional Vice President and Regional Nurse to review the incident, investigation measures and next steps. 6. On [DATE], the Administrator implemented a 1. Visitor Sign In/Out procedure. 2. Visitors will be given a document upon signing in that provides education regarding the safety and security of our patients. This will be an ongoing procedure. 7. On [DATE], the Regional Vice President 1. provided education to the Administrator on job description, roles and responsibilities and duty to ensure that the center uses its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each patient. 2. The Regional Vice President and the Regional Nurse provided education to the Administrator on the Wandering Patient Protocol (patient behavior should be reviewed with patient, responsible party, family members and interdisciplinary team; the center cannot inhibit the patient's leaving the center if he/she so chooses without a court-appointed guardian; the center should initiate efforts to protect the patient from injury; the center may have a door alarm system; Notify Administrator and Director of Nursing, local law enforcement, responsible party, attending physician; and Emergency Preparedness Plan for Missing Patients (Notify Administrator ASAP, Form Search Teams, Thoroughly search the premises, Notify the patient representative, notify the attending physician, notify the appropriate agencies). The Regional Vice President re-educated the Administrator on her role in the Quality Assurance Performance Improvement process. The Regional Vice President, Regional Nurse and Administrator reviewed the residents was performed to determine moving forward. In an effort to prevent reoccurrence of elopement, the Administrator was educate by the RVP and regional support teams on proper ways to ensure patient safety. 8. On [DATE], the Administrator and Director of Nursing provided education to center staff on elopement prevention and response - 4 of 5 RN' s, 13 of 14 LPN's, 28 of 33 C.N.A's, 1 of 1 Admissions Director, 7 of7 Dietary Staff, 7 of 9 Environmental Services, 1 of 1 Maintenance Director, 3 of 3 Activities, 1 of 1 Social Services, 1 of 1 Social Service Director, 1 of 1 Financial Controller, 1 of 1 Human Resource, and 1 of 1 Medical Records. Education provided included: How to assess the patient (focus on determine resident's purpose for attempting to leave), how to identify those at risk for elopement and identifying them, patient care plan (activity and social programs to occupy patients), Communication (resident sign in/out), Emergency Preparedness (Notify Administrator ASAP, Form Search Teams, thoroughly search the premises, Notify the patient representative, notify the attending physician, notify the appropriate agencies). 9. On [DATE], the Regional Vice President and Regional Engineering and Safety Manager made thorough environmental rounds to identify any potential risk factors and areas addressed as indicated. There were no noted potential risk factors or areas. All gates were locked and all doors were secure. The Regional Vice President and Regional Engineering and Safety Manager reviewed findings with the Administrator. 10. On [DATE] the Ad-hoc (impromptu) QAPI team will review the investigation to date and all interventions implemented to determine and additional mechanisms for preventing further occurrence. All findings will be entered the QAPI program and will be reviewed until compliance is achieved. The regional vice president will continue to provide ongoing education to the Administrator and any abnormal findings related to patient safety will be entered in the QAPI program until compliance is achieved. If any abnormal findings concluded, regional vice president will re-educate administrator and perform disciplinary action if needed. The State Survey Agency validated removal of the Immediate Jeopardy as follows: 1. Interview on [DATE] at 4:00 p.m. with Administrator revealed that she had initated the Emergency Preparedness on [DATE]. Record review revealed that Administrator completed actions per the Emergency Preparedness Missing Person Plan. Interview on [DATE] at 11:15 a.m. with DON and ADON revealed that they had accounted for all residents residing in the facility. Record review revealed that DON and ADON visually accounted for all patients in the center using the resident roster. Interview on [DATE] at 11:30 a.m. with Maintenance Director revealed they had ensured all exit doors and gates were closed at locked on [DATE]. Record review revealed that the Maintenance Director checked all exit doors and gates. Interview on [DATE] at 3:45 p.m. with Administrator revealed that the residents were re-assessed for Elopement Risks. Record review revealed that DON and ADON re-assessed all patients for Elopement Risk. Interview on [DATE] at 11:00 a.m. with DON, ADON, RAI Director, and RCC revealed that all residents were assessed for elopement risk and grouped according to status and care plans had been revised if indicated on [DATE] and [DATE]. Record review revealed that R#2, R#3, R#4, R#5, R#6, R#7, R#8, R#9, R#10, R#11, R#12, R#13, R#14, R#15, and R#16 care plans have been updated and revised. Record review revealed on [DATE] the Administrator initiated the Emergency Preparedness Missing person plan, was the Incident Commander, and organized teams to search the center, surrounding area, and that all staff participated. All residents were accounted for except R#1, The DON/ADON re-assessed all residents for Elopement risk and grouped the residents according to risk of elopement for medium and high risks. 2. Interview on [DATE] at 2:05 p.m. with the Sheriff's Deputy and Georgia Bureau of Investigation and confirmed with the Administrator and Regional Vice President on [DATE] at 4:45 p.m. revealed Candler County Sheriff's Office Investigation Reports were contacted on [DATE] and that the investigation was pending. Record review revealed Candler County Sheriff's Office Investigation Reports were contacted on [DATE] and that the investigation was pending. 3. Interview on [DATE] at 4:00 p.m. with Administrator and Regional Vice President confirmed that the resident's family and physician were notified on [DATE]. Record review revealed that Administrator notified resident's sister and resident's physician on [DATE] at 2:00 p.m. 4. Interview on [DATE] at 11:00 a.m. with Regional Vice President, DON, CNA SSS, CNA CCC and CNA YY revealed that they had been educated on what to do when the door alarms went off. Record review revealed that staff members were posted by the door until audible alarm was placed on the door on [DATE] at 5:00 p.m. and that education was provided to the staff of the installation of the alarm and what to do if the alarm went off. Multidisciplinary staff members were interviewed. All staff stated they had attended in-services related determining the difference between wandering and elopement, about goals and interventions for wandering and elopement, the causes and risks for wandering and elopement, identifying and care planning residents that are at risk for wandering and elopement, providing safety and security for those at risk for wandering and elopement, elopement drills, the appropriate purpose and use of alarmed doors and exits, what to do if a door alarm does alarm, what to do in the event of a missing person, zone defense rounds, ensuring all safety measures are in place including rounds to ensure all gates are locked and doors are secure, and utilizing the CNA care plans. These interviews were conducted on [DATE] as follows: LPN UU at 8:30 a.m., LPN VV at 8:45 a.m., CNA WW at 8:50 a.m., RCC Nurse Supervisor XX at 9:00 a.m., CNA YY at 9:40 a.m., LPN ZZ at 9:45 a.m., LPN AAA 9:50 a.m., CNA BBB at 9:55 a.m., CNA CCC at 10:00 a.m., CNA DDD at 10:05 a.m., CNA EEE at 10:10 a.m., LPN FFF at 10:15 a.m., CNA GGG at 10:20 a.m., CNA HHH at 10:25 a.m., CNA III at 10:30 a.m., Housekeeper JJJ at 8:55 a.m., Housekeeper KKK at 9:00 a.m., Maintenance LLL at 9:05 a.m., Activity Director MMM at 9:10 a.m., Social Services NNN at 9:15 a.m., Human Resources OOO at 9:20 a.m., Medical Records PPP at 9:25 a.m., CNA QQQ at 10:35 a.m., CNA RRR at 10:45 a.m., CNA SSS at 10:45 a.m., Dietary Aide TTT 10:50 a.m., Dietary Aide UUU at 10:55 a.m., ADON DD, RAI Coordinator EE, Admissions FF, Human, Resources GG, Financial Controller, HH, RCC II, Activity Director KK, Social Services LL, Maintenance NN at 11:00 a.m. Record review of in-service sign in sheets revealed that 68 staff attended this in-service and 10 staff did not attend and were educated via phone by the Administrator. 5. Interview on [DATE] at 11:30 a.m. with Regional Vice President confirmed that an Ad-Hoc QAPI meeting was held on [DATE]. Record review revealed that a Performance Improvement Committee met at 1:00 p.m. on [DATE]. 6. Interview on [DATE] at 11:45 a.m. with Regional Vice President revealed that visitors need to sign in and out of the facility. Record reviewed revealed visitors are required to sign in and out and patient safety education is being provided to visitors as they are signing in. 7. Interview on [DATE] at 9:20 a.m. with the Regional Vice President revealed they provided education to the Administrator on her job description, roles and responsibilities and duty to ensure that the center uses its resources effectively and efficiently. Record review revealed that Administrator was re-educated by Regional Vice President. 8. Multidisciplinary staff members were interviewed. All staff stated they had attended in-services related determining the difference between wandering and elopement, about goals and interventions for wandering and elopement, the causes and risks for wandering and elopement, identifying and care planning residents that are at risk for wandering and elopement, providing safety and security for those at risk for wandering and elopement, elopement drills, the appropriate purpose and use of alarmed doors and exits, what to do if a door alarm does alarm, what to do in the event of a missing person, zone defense rounds, ensuring all safety measures are in place including rounds to ensure all gates are locked and doors are secure, and utilizing the CNA care plans, and how to assess the patient, how to identify those at risk for elopement and identifying them, patient care plan, Communication, Form search teams, thoroughly search the premises, notify patient representative, and physician, and the appropriate agencies. These interviews were conducted on [DATE] as follows: LPN UU at 8:30 a.m., LPN VV at 8:45 a.m., CNA WW at 8:50 a.m., RCC Nurse Supervisor XX at 9:00 a.m., CNA YY at 9:40 a.m., LPN ZZ at 9:45 a.m., LPN AAA at 9:50 a.m., CNA BBB at 9:55 a.m., CNA CCC at 10:00 a.m., CNA DDD at 10:05 a.m., CNA EEE at 10:10 a.m., LPN FFF at 10:15 a.m., CNA GGG at 10:20 a.m., CNA HHH at 10:25 a.m., CNA III at 10:30 a.m., Housekeeper JJJ at 8:55 a.m., Housekeeper KKK at 9:00 a.m., Maintenance LLL at 9:05 a.m., Activity Director MMM at 9:10 a.m., Social Services NNN at 9:15 a.m., Human Resources OOO at 9:20 a.m., Medical Records PPP at 9:25 a.m., CNA QQQ at 10:35 a.m., CNA RRR at 10:45 a.m., CNA SSS at 10:45 a.m., Dietary Aide TTT 10:50 a.m., Dietary Aide UUU at 10:55 a.m., ADON DD, RAI Coordinator EE, Admissions FF, Human, Resources GG, Financial Controller, HH, RCC II, Activity Director KK, Social Services LL, Maintenance NN at 11:00 a.m. Record review of in-service sign in sheets revealed that 68 staff attended this in-service and 10 staff did not attend and were educated via phone by Administrator. 9. Interview on [DATE] at 4:00 p.m. with Regional Vice President revealed environmental rounds had been completed to ensure all doors and gates were locked. Record review revealed that environmental rounds were made by Regional Vice President and Regional Engineering and Safety Manager were completed on [DATE] and all gates were locked and doors were secure. 10. Interview on [DATE] at 11:30 a.m. with Regional Vice President confirmed that an Ad-Hoc QAPI meeting was held on [DATE]. Record review revealed that a Performance Improvement Committee met at 1:00 p.m. on [DATE] and that findings will be reviewed until compliance is achieved and the Regional Vice President will continue to provide ongoing education to the Administrator. 10. Interview on [DATE] at 11:30 a.m. with Regional Vice President confirmed that an Ad-Hoc (impromptu) QAPI meeting was held on [DATE]. Record review revealed that a Performance Improvement Committee met at 1:00 p.m. on [DATE] and that findings will be reviewed until compliance is achieved and the Regional Vice President will continue to provide ongoing education to the Administrator. | 2020-09-01 |