cms_GA: 340
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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340 | SIGNATURE HEALTHCARE OF MARIETTA | 115206 | 811 KENNESAW AVENUE | MARIETTA | GA | 30060 | 2019-02-03 | 835 | J | 1 | 0 | JJVJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews and review of clinical records it was determined that the Administration failed to ensure the facility was administered in a manner that enabled it to use its resources effectively and efficiently to ensure each resident attained or maintained the highest possible level of physical, mental and psychological well-being. Resident #1 injured his finger on 12/27/18. The Administrator was unaware of the extent of the injury until 1/4/19. The facility census was 123. An abbreviated survey was initiated on 1/10/19 and concluded on 2/3/19 to investigate complaint number GA 960 to determine compliance with Federal and State Long Term Care Requirements, 42 CFR, Part 483, Subpart B, Requirements for Long Term Care Facility. The allegation of deficient practice related to resident neglect was substantiated. The following deficiencies were cited. The census on 2/3/19 was 126. A determination was made that a situation in which the facility's non-compliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. On 1/30/19 at 5:05 p.m. the facility's Administrator and the Director of Health Service (DHS), were informed of an Immediate Jeopardy (IJ). The non-compliance related to the Immediate Jeopardy was identified to have existed on 12/27/18. At the time of the exit on 2/3/19, the State Survey Agency had not received an acceptable Creditable Allegation of Compliance, therefore, the IJ was ongoing. The immediate jeopardy is outlined as follows: The IJ was determined to exist as of 12/27/18, when R#1 cut the tip of the left pinky finger with a fingernail clipper. Clinical staff treated and applied a self-adhering bandage/wrap to the finger. The resident was transferred to the hospital on [DATE] and diagnosed with [REDACTED].#1 being hospitalized , subsequently the affected area was surgically removed. Immediate Jeopardy was related to the facility's non-compliance with the program requirements as follows: CFR:483.21(b)(1)Develop/Implement Comprehensive Care Plan (F656 Scope and Severity: J) CFR:483.21(b)(3)(i)Services Provided Meet Professional Standards (F658 Scope and Severity: J) CFR:483:25 Quality of Care (F684 Scope and Severity: J) CFR 483.70 Administration (F835 Scope and Severity: J) Additionally, Substandard Quality of Care was identified with the requirements at CFR:483:25 Quality of Care (F684 Scope and Severity: J). Finding include: On 1/30/19 at 4:00 p.m. interview with former Administrator CC revealed that he was the Administrator at the facility from 6/1/17 until 1/16/19 and had recently been reassigned to another position in the facility. He revealed that he was unaware of R#1 injury and the dressing treatment until 1/4/19 after the resident was admitted to the hospital. He revealed that the Director of Nursing (DHS) and staff responded to the incident to prevent a further incident by removing all the self-adhering dressing from treatment carts. The Administrator stated he informed the phlebotomist not to leave any of the dressing behind after drawing resident's blood for the lab. He later followed up with a family member on the status update of the residents health. During an interview on 1/30/19 at 4:05 p.m. with the current Interim Administrator revealed that he started working at this facility on 1/16/19. During an interview on 1/31/19 at 2:02 p.m. the Regional Vice President stated that he and his team which includes: The Clinical Vice President, State Operation Manager as well as the Regional Consultant is overseeing and working directly with the facility on a daily basis to ensure that the A[NAME] is developed and ensure that the agreement with the State is carried out. He also stated that the current Interim Administrator at the facility agreed to stay on as the Administrator until he replaced. The expectation of hiring a permanent Administrator should be within the next 30 days. and ask that if he can be any service to call him directly. During a post survey interview on 2/13/19 at 2:15 p.m. Administrator CC it was clarified that he was notified of the incident regarding R#1 on 1/1/19 by Physician BB. Continued interview with Administrator CC it was learned that he did not attend the facility's Clinical Morning Meetings. Refer to F 656, F 658, F 684 | 2020-09-01 |