cms_GA: 2969
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 |
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2969 | PRUITTHEALTH - FITZGERALD | 115617 | 185 BOWEN'S MILL HIGHWAY | FITZGERALD | GA | 31750 | 2019-07-03 | 607 | J | 1 | 0 | KWBX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews, medical record review, review of written statements, review of the facility policy titled, Reporting Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation and review of the facility policy titled Abuse Prevention and Reporting and review of the facility policy titled, No Retaliation for Good Faith Reporting of Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property it was determined that the facility failed to implement the protection and reporting component of their abuse policy when two LPN's failed to report an incident of sexual abuse for one of 14 residents (R#7) reviewed for abuse and the facility failed to provide protection for one of one residents ( R#7) after an allegation of sexual abuse was made on (MONTH) 8, 2019. The facility census was 69 residents. On (MONTH) 25, 2019, 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 Health Services (DHS), Acting Assistant Director of Health Services (AADHS), the newly hired Assistant Director of Health Services (ADHS), and the Regional Vice President (VP) were informed of the Immediate Jeopardy on (MONTH) 25, 2019 at 5:25 p.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on (MONTH) 8, 2019. The Immediate Jeopardy continued through (MONTH) 27, 2019 and was removed on (MONTH) 28, 2019. The facility implemented a Removal Plan related to the Immediate Jeopardy on 6/27/19. The Immediate Jeopardy is outlined as follows: On (MONTH) 8, 2019 Resident (R) #6, a cognitively intact male, was observed by two Certified Nursing Assistants (CNA) in R#7's (a cognitively impaired female) room with his hand under R#7's covers, and was kissing the resident on her face. Per staff interviews, review of written statements and review of the police report, R#7 was fearful, crying and complained of pain to her perineal area. The two CNA's immediately reported the incident to two Licensed Practical Nurses (LPN). However, the LPN's failed to immediately report the incident to Administration which lead to a failure to protect R#7 resulting in R#6 re-entering her room again on (MONTH) 9, 2019 which caused R#7 continued fear. The Immediate Jeopardy was related to the facility's noncompliance with the program requirements at 42 C.F.R. 483.12(a)(1), Free from Abuse and Neglect (F600), Scope/Severity: J and 42 C.F.R. 483.12(a)(1), Develop/Implement Abuse/Neglect Policies (F607), Scope/Severity: J). Additionally, Substandard Quality of Care was identified with the requirements at 483.12(a)(1), Free from Abuse and Neglect (F600, Scope/Severity: J); 42 C.F.R. 483.12(a)(1), Develop/Implement Abuse/Neglect Policies (F607, Scope/Severity: J). A Removal Plan was received on (MONTH) 26, 2019 related to 42 C.F.R. 483.12(a)(1), Free from Abuse and Neglect (F600) and 42 C.F.R. 483.12(a)(1), Develop/Implement Abuse/Neglect Policies (F607). Based on observations, record reviews, interviews and review of the facility's policies as outlined in the Removal Plan, it was validated that the corrective plans was implemented therefore, the immediacy of the deficient practice was removed on (MONTH) 28, 2019. The facility remained out of compliance at a lower scope and severity of D while the facility continued management level staff oversight of ensuring that staff and residents are educated on the facility's abuse policy and know what abuse is, when to report abuse, and how to report abuse. This oversight process included the analysis of the facility staffs' conformance with the facility's abuse policies and procedures governing the timely and accurate reporting of abuse and implementing interventions in their abuse policy. In-service materials and records were reviewed. Observations and interviews were conducted with staff and residents to ensure they demonstrated knowledge of facility policies and procedures regarding what is abuse and when and how to report abuse. Findings include: A review of the facility policy titled, Prevention of Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property documented the definition of sexual abuse is non-consensual sexual contact of any type with a patient. A review of the facility policy titled, Reporting Patient Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Property documented the following procedure: Any allegation, suspicious, or identified occurrence involving patient abuse, neglect, exploitation, mistreatment, and misappropriation of property, including injuries of an unknown source, should be immediately reported to the Administrator of the provider entity. A review of the facility policy titled, No Retaliation for Good Faith Reporting of Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property documented the following procedure under the section titled Protection: During an active investigation of patient abuse, neglect, exploitation, mistreatment or misappropriation of patient property, when there is substantial evidence that such has occurred, the provider should take all reasonable efforts to protect the affected patient(s) from harm. R#6 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The 30-day Minimum Data Set (MDS) assessment, dated 5/15/19, indicated that the resident was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15. The resident was also assessed as requiring minimal assistance from staff. The resident was independent for locomotion on and off the unit and utilized a wheelchair and walker for mobility. R#7 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. R#7 was assessed by the facility on the 5/4/19, MDS as having a BIMS score of six indicating that the resident was severely cognitively impaired with decision making skills and demonstrated inattention. The resident required extensive assistance of one person for bed mobility and was nonambulatory. She was totally dependent on staff for dressing, hygiene and bathing. She was assessed as having functional limitation in range of motion of the upper extremity on one side and impairment on both sides of the lower extremities. During an interview with Licensed Practical Nurse (LPN BB), (a.m.- 7 p.m. shift) on 6/18/19 at 4:08 p.m., revealed that on Saturday, 6/8/19, after 7:00 p.m., a CNA came and reported to LPN AA that R#6 was kissing R#7 on her face and that he had his hand under the covers. LPN BB stated she and the other nurse, LPN AA, went down to R#7's room and asked R#6 to leave. LPN BB stated that R#6 got mad and called them racists. Further interview with LPN BB revealed that on 6/9/19 around shift change she was walking by R#7's room and her eyes met R#7's eyes. LPN BB stated that R#7 looked fearful. LPN BB stated that she saw R#6 was in the room talking to R#7's roommate and then R#6 went over to R#7's bed. LPN BB stated that R#7 continued to have a fearful look on her face. LPN BB went into the room and asked R#7 if she wanted R#6 in her room and R#7 responded, no. LPN BB stated she then asked R#6 to leave, and that R#6 got mad and left. Continued interview with LPN BB revealed that on 6/9/19 she told the Acting Assistant Director of Health Service (AADHS) that R#6 had been in R#7's room twice and that R#7 was fearful. After that, CNA DD told the AADHS what occurred on 6/8/19, when they saw R#6 in R#7's room kissing her on the face with his hand under the covers. LPN BB stated that the AADHS said Oh my God, that has to be reported. During an interview on 6/19/19 at 11:05 a.m., the Acting Assistant Director of Health Services (AADHS) confirmed that she first became aware of the physical contact between R#6 and R#7 on 6/9/19, after R#6 had re-entered R#7's room on 6/9/19. When they told her what occurred on 6/8/19 and 6/9/19, she made them aware that the incident should have been reported right away. During an interview with LPN SS on 6/19/19 at 11:05 a.m., she stated she had been off work when all of this happened. She stated she returned to work on 6/10/19, and was assigned to the floor that R#7 resided on but no one informed her of the incident until after R#6 left the faciity on [DATE]. LPN SS also stated nobody told her to watch to ensure that R#6 did not go near R#7. During a telephone interview with LPN AA (p.m.-a.m. shift) on 6/19/19 at 11:35 a.m., she stated that she was taking report with the day shift nurse on 6/8/19 around 8:00 p.m., when the CNA's came to her and said R#6 had his hands under R#7's covers. When she and LPN BB went to the room she asked R#6 to leave the room. R#7 told her that he touched her, but she did not specify where. She stated she examined R#7 and noticed her brief was on tight and there was no redness or swelling. She also stated that R#6 was in R#7's room morning, noon and night but she never saw any behaviors prior to this. She stated she did not report this to anyone because she thought the residents were boyfriend and girlfriend. LPN AA stated the next night, 6/9/19, when she came on duty LPN BB told her R#6 had been in R#7's room again and she made him leave. LPN BB said she did not call the physician on 6/8/19. LPN AA further stated that LPN BB told her when she worked on 6/9/19 that there were no special instructions given to them to start one-on-one monitoring with R#6 or to keep R#6 out of R#7's room. During an interview with the Administrator and the Director of Health Services (DHS) on 6/20/19 at 9:50 a.m., they stated that light duty CNA's were on the hall watching R#6 and would shadow the resident if he came out of his room. They stated one of the light duty CNAs would have been assigned to watch the resident. Further interview revealed that the Administrator and DHS were unable to show the surveyor on the actual assignment sheets for 6/9/19, 6/10/19 and 6/11/19 who was assigned to watch R#6. During an interview with LPN EE on 6/26/19 at 10:45 a.m., she stated that there were no light duty CNAs working the night shift (7 p.m.-7 a.m.) on 6/9/19, or on 6/10/19, and stated that there were no staff actually assigned to stand in the hallway and watch R#6. LPN EE stated staff would just note where the resident was as they were out doing their assignments. Review of the Pruitt Health Daily Nursing Assignment Form revealed the following: On 6/8/19 the 7 p.m.-7 a.m., shift had two LPN's and three CNA's working with assignments. On 6/9/19 the 7 a.m.-7 p.m., shift had two LPN's and four CNA's with one light duty CNA who made beds, answered call lights and assisted with meals. The 7 p.m.-7 a.m., shift had two LPN's and three CNA's with no light duty staff scheduled. All the staff had assignments. On 6/10/19 the 7 a.m.-7 p.m., shift had two LPN's, four CNA's who had assignments and one CNA in training who also had an assignment. There were two light duty CNA's who were either assigned to the hydration cart and to accompany residents to appointments on transport. The 7 p.m.-7 a.m., shift had two LPN's and five CNA's who all had an assignment. On 6/11/19 the 7 a.m.-7 p.m., shift had two LPN's and five CNA's who had assignments and two light duty CNA's who either were assigned hydration or to accompany residents to appointments on transport. During an interview and review of the assignment forms with the AADHS on 6/26/19 at 10:45 a.m., she stated she was responsible for making out the assignment sheets. In reviewing the assignment sheets, she stated there were no light duty CNA's scheduled on 6/8/19 on the 7 p.m.-7 a.m., shift. She stated on 6/9/19, there was only one light duty staff who worked from 7 a.m.-3 p.m., making beds, answering call lights and assisting with meals. She stated there were no light duty staff on the 7 p.m.-7 a.m., shift and all of the staff had an assignment. She stated on 6/10/19 a.m.-p.m., there were three light duty CNA's. One was assigned hydration who worked from 8:00 a.m.- 4:30 p.m. passing out ice, water and snacks, another CNA was on transport and the third CNA worked from 7:00 a.m. -3:00 p.m., with another CNA who had an assignment. She stated the 7:00 p.m. - 7 a.m. shift did not have light duty staff and all the staff had assignments that night. She stated on 6/11/19, 7 a.m.- 7 p.m., had two light duty CNA's. One was on transport and the other on hydration from 8:00 a.m. - 4:30 p.m. Although the facility indicated R#6 was put on one-on-one observation there was no evidence that the facility called in additional staff to provide this supervision, and there was no evidence that the facility had light duty CNA's scheduled for the 7 p.m. - 7 a.m., shift. from 6/8/19 through 6/11/19, when R#6 was transferred to a psychiatric hospital. The facility implemented the following to remove the Immediate Jeopardy: 1. Resident #6 was put on one-on-one supervision until he was transferred to another facility on 6/11/19. Resident #6 will not be returning to the facility. On 6/9/19 both LPN's were suspended. LPN #1(AA) was subsequently terminated for not timely reporting incident. LPN #2 (BB) received education on abuse and timely reporting by the DHS before returning to work on 6/17/19. Resident #7 had a quarterly Minimum Data Set (MDS) Assessment on 5/4/19 resulting in a Brief Interview for Mental Status (BIMS) score of 6. Resident #7 was assessed by the DHS on 6/9/19 regarding her emotional and physical well-being and sent to the ER for emergency evaluation as well with no reported negative outcome. Resident #7 has been assessed daily for her emotional/behavioral health by the DHS since 6/9/19 and has been added to our Behavior Management Program on 6/9/19 and reviewed weekly. Resident #7 is also scheduled for a behavioral health services check with an outside Psychiatrist on 7/10/19. 2. The abuse policy was reviewed by corporate on 1/8/19 and then again by the Area Vice President and Administrator on 6/25/19. Our review of the policy determined the policy was in good standing and well developed and included the seven components; abuse identification, types of abuse, right to be free of abuse, investigating abuse, prevention of abuse, protecting against abuse, and reporting of abuse (2-hour timeline). 3. All residents have the potential to be affected. The ADHS, DHS, and Social Worker completed interviews regarding our facility abuse policy with cognitive residents that have a BIMS score between 10-15 to rule out any questions or concerns. Questions include do you have any questions on our abuse policy? and per policy do you know who to report to if you or someone has been abused in our facility? All interviews were completed between 10:00 a.m. and 1:00 p.m. on 6/27/19 with no adverse findings reported. 4. At the time of the interviews all forty-three cognitive residents were educated on the facility abuse policy including the seven components; abuse identification, types of abuse, right to be free of abuse, investigating abuse, prevention of abuse, protecting against abuse, and reporting of abuse. On 6/27/19 all forty-three cognitive residents received a copy of the abuse policy. The families, responsible parties, and/or power of attorneys, of the twenty-two residents with a BIMS lower than 10 were mailed the abuse policy on 6/27/19. 5. All staff was in-serviced by the DHS and Clinical Competency Coordinator (CCC) on our abuse policy and the seven components; abuse identification, types of abuse, right to be free of abuse, investigating abuse, prevention of abuse, protecting against abuse, and reporting of abuse. Scenarios were also provided to staff on abuse identification of abuse indicators with non-cognitive residents to observe for fearfulness, anger, stress, defensiveness, anxiety, worrying, or fear of being alone with staff. In-service education was initiated on 6/25/19 at 7:30 p.m. until 11:00 p.m. and completed 6/26/19 between 9:00 a.m. and 11:00 a.m. 5 of 5 RN's, 12 of 12 LPN's, 21 of 21 CNAs, 8 of 8 housekeeping, 7 of 7 administrative, 6 of 6 dietary, 4 of 4 therapy, and 1 of 1 maintenance have all been in-serviced. 100% of staff was competed on 6/26/19. A copy of the abuse policy was posted on the bulletin board located at the front entrance and by the therapy department for all visitors and staff members to have for review. A list of names and contact numbers of the Administrator, DHS, and CCC were also posted. 6. Newly hired staff will be in-serviced on the abuse policy on the first day of hire during orientation and annually by the CCC. 7. The CCC and/or Social Worker will interview 5 residents a week, for 6 weeks on the above-mentioned abuse policy questions starting 6/27/19. The CCC will report any adverse findings to the administrator immediately. The Administrator will report adverse findings to the state agencies, Ombudsman at (phone number), and the Facility Regulation Division at (phone number). The DHS or ADHS will also report adverse findings to the physician and/or Medical Director. The CCC and/or Social Worker will also interview 5 staff members per week, Monday through Friday on both shifts 7 a.m. to 7 p.m. and 7 p.m. to 7 a.m., for 6 weeks. The interview questions are on our abuse policy to make sure staff is familiar with our abuse policy. Adverse findings will be reported to the Administrator immediately for proper reporting to state agency. 8. The immediate jeopardy was communicated with the Senior Nurse Consultant, Area Vice President, Senior Vice President of Clinical Services, and COO of Community Services on 6/25/19 4:40 p.m. An Ad hock meeting was held with the medical director, the administrator, DHS, ADHS, Licensed Practical Nurse, senior nurse consultant, area vice president, restorative nurse and certified nursing assistant on 6/27/2019 to discuss the immediate jeopardy finding and the allegation of credible compliance. 9. The Administrator will take all findings to the QAPI committee for action as needed monthly beginning 06/26/19, times 3 months. 10. All immediate corrective actions will be completed by 6/27/19. The State Agency validated the following to remove the Immediate Jeopardy: 1. Record review revealed a Physician order for [REDACTED]. A Physician order dated 6/11/19 for R#6 that documented may transfer to DCH via 1013; Res (Resident) medically stable for transport. Review of a Nurses Note dated 6/11/19 at 2:00 p.m., documented Resident transported to psych in-patient facility via 1013. Record review of a One on One Monitoring form dated 6/9/19 at 8 p.m., revealed the following instructions documented: Staff member is to closely monitor res. If he leaves his room for any reason. Day 1 Sunday Res. Placed on 1:1 monitoring at 8 p.m., d/t (due to) alleged sexual assault. Immediately following incident, resident returned to his room and was monitored by CN[NAME] Night 1 Sun (Sunday): Stayed in bed all night did not leave his room. Day 2 Mon (Monday) 6-10 - Walked in hall for short time, returned to bed and didn't come out of room. Monitored him while out of bed. Night 2 Mon 6-10 Charge nurse monitored resident and was given instruction to observe if resident left room for any reason. I served as Charge Nurse (CN) and he did not leave his room. Day 3 Tuesday 6/11/19 Watched until discharged , walked only in room and returned to bed. Behavioral Symptom Screening Form for R#7 dated 6/9/19, 6/12/19, 6/19/19, 6/26/19, documented the following: Resident was the victim of an alleged sexual assault from another male resident. Resident appeared frightful and scared. 2. Record Review of the facility's abuse policy revealed that it was last revised 1/8/19 the policy includes the seven components including: screening, training, prevention, identification, investigation, protection, reporting and response to abuse. The policy addresses misappropriation of property, exploitation, mistreatment, mistreatment and misappropriation of property. Investigating abuse, No retaliation, prevention of abuse, reporting. 3. Review of the Census list dated 6/25/19 revealed that 43 residents are marked as being interviewed and that 22 residents are documented as having skin assessments. Record review revealed that Body Audit forms were completed for each of the 22 residents without any adverse findings noted. Further review revealed 43 Resident interviews regarding Abuse. Specific questions included: Has staff, a resident, or anyone else here abused you? Have you seen any resident here being abused? Each form documents that each of the 43 residents received education on how to report suspected abuse/neglect. There were no negative findings of abuse noted. Each form documented that education was provided regarding the facility abuse policy. Interview on 6/28/19 at 3:05 p.m., via telephone with a family member of resident C stated the Social Worker (SW) called him on 6/27/19 to talk about abuse and the policy. She told him they would be mailing him a copy of the policy and was to sign the form and mail it back. Interview on 6/28/19 at 4:40 pm with R D stated the staff gave her a copy of the abuse policy and procedure yesterday and talked to her about abuse and the policy. R D stated the staff also gave her roommate a copy. Interview on 6/28/19 at 5:00 pm with R [NAME] stated she had a copy of the abuse policy which was sitting on her overbed table that they brought her yesterday. 4. Record review revealed 43 resident interviews regarding Abuse. Specific questions included: Has staff, a resident, or anyone else here abused you? Have you seen any resident here being abused? Each form documents that each of the 43 residents received education on how to report suspected abuse/neglect. There were no negative findings of abuse noted. Each form documented that education was provided to each resident regarding the facility abuse policy. Record review of the Census list revealed letters were mailed, on 6/27/19, to Family Members and/or Responsible Party, that the facility would like to ensure our family members, responsible parties, and residents are aware of our Abuse Policy & Procedure that details the types of abuse, who to report abuse to, time to report, investigation, possible staff disciplinary actions, protection of resident, facility will investigate all allegation of abuse. The letter also documents that the facility will be having a Family Council meeting on 7/10/19 to further discuss abuse policies. Record review of the Census list documents for each resident documented that one on one education was provided to the resident and documents that letters were mailed to the responsible party and the date the letters were mailed (6/27/19). 5. Record review of the Inservice Education Program Summary Record dated 6/27/19 revealed that the abuse policy and procedure was reviewed. In addition, symptoms of abuse in non-cognitive residents: fearfulness, anger, stress, defensiveness, anxiety, worry or fear of being alone with person. Forty-one staff members are noted to have signed this form. Record review of the Active Employee Listing revealed that the facility has 59 active employees. Fifty-nine employees signed Inservice Education Program Attendance Record Form. Review of the Inservice Education Program Summary Record Form dated 6/25/19 through 6/26/19 revealed that education was provided regarding abuse, what is abuse, types of abuse, any suspected abuse must be reported immediately to the Administrator, no matter what time of day or what time. Abuse scenario reviews. Interview with staff on 6/28/19 revealed that staff had been educated on the components of the abuse policy, and received in-services regarding what is abuse, types of abuse, signs of symptoms of abuse for cognitively impaired residents, who to report abuse to, when to report abuse, and how to report abuse. Interviews included the following staff and residents: LPN FF ( 6/28/19 at 11:00; CNA GG- 1:41 p.m.; at 11:49 a.m. Financial Counselor HH; 12:08 p.m. Speech language Pathologist II; at 12:51 p.m. with Floor Tech JJ; at 1:10 p.m. with CNA KK and CNA LL; at 1:16 p.m. with the DHS; at 1:30 p.m. with HK (QQ); at 1:34 p.m. Maintenance & Housekeeper MM; at 1:37 p.m. Laundry Aide NN; at 1:40 p.m. with PTA OO; at 1:47 p.m. LPN Unit Manager PP; at 1:40 p.m. with HK RR; at 1:50 p.m. LPN SS (7A-7P) (SS); at 2:00 p.m. with Dietary TT; at 2:30 p.m. with Dietary UU; at 3:05 p.m. via telephone with, son of resident C; at 4:40 p.m. with RD; at 4:57 p.m. with Area Vice President, Senior Nurse Consultant, the DHS, and ADHS; at 3:55 pm- CNA VV (7P-7A); 6/28/19 at 4:10 p.m. with LPN WW (7P-7A); at 4:30 p.m. with LPN XX (7P-7A); 6/28/19 at 5:00 p.m. RE. 6. Record review revealed the facility had two new employees. Interview with LPN FF on 6/28/19 at 11:00 a.m., revealed that her first day was Wednesday and that she had received the following training: Abuse training - types of abuse physical, verbal, mental, sexual; right not to be abused, report, report immediately within two hours. If you see, remove abuser immediately - and contact DHS and Administrator. Check on the abused monitor for fear, anxiety, can't talk - tense, flinching. Received on the first day and every day since then. I immediately report to Administrator or DHS. Phone numbers are on bulletins. Besides Abuse policy. I know how to get abuse policy. A copy of policy is posted. Always report. Person is safe. Even if resident is confused you treat as any allegation of abuse and you report immediately. Protect resident. Separate the residents and watch perpetrator. Protection is priority. Delegate staff members. 7. Record review revealed that The Clinical Care Coordinator (CCC) and Social Worker (SW) interviewed five residents for the week of 6/27/19 regarding abuse and five additional Head to Toe assessments were completed for cognitively impaired residents. No adverse findings were noted. Further review revealed five Staff Abuse Questionnaires that included the following questions: What training have you received at this facility regarding abuse and neglect? How often is training held, what would you do if a resident becomes agitated and physically aggressive while you were providing care? Per our policy who would you report alleged abused to? List two examples of abuse, what would you do if you discovered two residents fighting? What would you do if you saw a staff member hit a resident? What would you do if the staff member you saw hit a resident was back at work the next day performing care to the residents? Do you know where the numbers are to report abuse and neglect? Can you tell me per our abuse policy, how quickly does the facility have to report alleged abuse to the state? 8. Review of the Ad hoc QAPI meeting notes revealed an Ad hoc meeting was held on 6/27/19 at 3:00 p.m., and that the following were in attendance: Physician, three LPN's, one RN, Administrator, Area Vice President, Senior Nurse Consultant, one CNA and topics discussed were ongoing complaint survey/IJ tags. Interview on 6/28/19 at 1:47 p.m., with the Area Vice President, Senior Nurse Consultant, Director of Health Services, and Assistant Director of Health Services revealed that an Ad hoc QAPI meeting was held 6/27/19 to discuss the findings with the Immediate Jeopardy tags. 9. Interview on 6/28/19 at 1:47 p.m. with the Area Vice President, Senior Nurse Consultant, Director of Health Services, and Assistant Director of Health Services revealed that the findings for the Immediate Jeopardy will be taken to the QAPI committee for action as needed. | 2020-09-01 |