cms_GA: 4376
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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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 4376 | NORTHEAST ATLANTA HEALTH AND REHABILITATION CENTER | 115504 | 1500 S JOHNSON FERRY ROAD | ATLANTA | GA | 30319 | 2016-11-09 | 328 | K | 1 | 0 | 3P2Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview and record review, the facility failed to ensure they provided necessary emergency respiratory supplies as well as an adequate power source to meet the needs of two residents (R28 and R29) residents that had tracheotomies (trachs) and required multiple medical apparatus including ventilator (machine to aid and/or deliver respirations). Review of the CMS Form 672, signed and dated by the Director of Nursing on 11/1/16, revealed no evidence of trachs, and 5 receiving respiratory treatments. The sample was seventy-seven (77) residents. A determination was made that 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. On 8/12/16 at 3:36 p.m. the Nursing Home Administrator (NHA) and the Director of Nursing (DON), were informed by the survey team of an Immediate Jeopardy (IJ) situation. The facility's failure to ensure all necessary respiratory related medical equipment for two residents (R28 and R29) with tracheotomies were readily available; and that a safe and appropriate power source was available for their medical equipment, placed residents at risk of serious harm or death effective on 6/25/16 Those failures left residents vulnerable to respiratory distress, and/or death. This failure increased the likelihood for serious harm to two (2) of 2 residents (R28 and R29) with tracheotomies, who: Required back-up replacement inner cannulas in the event their cannulas became dislodged and required emergency replacement. The facility did not ensure the necessary equipment for potential respiratory distress (Ambu bags -manual resuscitators- for both residents, and correctly sized replacement inner cannulas for their tracheotomies) was available, and; Required more electrical outlets to ensure effective delivery of care via medical apparatus than was available. The facility used power strips to provide the extra power that did not meet safety standards. It was not acceptable to obtain power for medical equipment other than directly from the wall. R28 and R29 required multiple medical apparatus (requiring a safe and reliable power source). Since some of their required equipment (oxygen, suction and nebulizers) were directly related to their compromised breathing status, that failure also rose to the level of immediate jeopardy (IJ). The residents were roommates and both required more electrical outlets (seven for R28 and six for R29) than the room provided (4 were available per resident). An acceptable Allegation of Compliance (AoC) was received on 8/19/16 and Healthcare Management Solutions, LLC in conjunction with the Georgia State Survey Agency validated that the Immediate Jeopardy was removed on 9/14/16, as alleged. However, to ensure that the education continues, policy and procedures are implemented, and the QAPI is implemented and functional, the scope and severity (S/S) for F328 was lowered to an E, while the facility develops and implements the Plan of Correction (PoC). Review of the CMS Form 671 signed and dated on 11/1/16 by the DON revealed there are no residents with trachs, and four (4) residents receiving respiratory treatments. Findings include: 1. On 8/12/16, at approximately 12:30 p.m., a family member (F1) of R28, came to the survey team and expressed his concern over the facility being able to provide the needed care for his family member. R28 was admitted to the facility on [DATE] from an acute hospital, out of state, without an onsite assessment. He had [DIAGNOSES REDACTED]. According to his admission Minimum Data Set (MDS) assessment, completed 7/6/16, his [DIAGNOSES REDACTED]. R28 was totally dependent on staff for all Activities of Daily Living (ADLs). Review of the care plan for R28 revealed the presence of the [MEDICAL CONDITION], but it did not list the type or size of the inner cannula. There was evidence to include having a back-up inner cannula or Ambu bag available for respiratory emergencies, or what to do if the inner cannula became dislodged. There was no evidence of a pressure relieving air mattress, although it was ordered by the physician. On 8/12/16, at approximately 12:30 p.m., F1 of R28 stated that he wanted to find out who he needed to call to address some concerns he had regarding care of R28. He stated the facility staff had, almost killed R28 three (3) times, if I had not been here then R28 would not still be here. He stated he was going to talk to the doctor and requested the complaint line number. On 8/12/16, at approximately 12:45 p.m., F1 stated that awhile back, maybe around mid-July, he entered the room of R28 to find him in bed. He appeared to be choking. When F1 asked R28 if he was choking, F1 stated R28 nodded yes. F1 ran to get the nursing staff for assistance. He stated they were not able to clear the airway with suctioning and the staff had called 911. F1 stated that someone from the facility had also called the respiratory therapist (RT) who stated she was close by and would come to the building. F1 also stated the RT was able to clear a mucus plug (an accumulation of mucus in the airway that occurs because a patient can't cough to clear their own airway) and his father was not transported to the emergency room per his request as he was no longer at risk. F1 described a second occasion where he had entered the room if R28 to find the water bottle (humidifier) on the tubing empty and he found a hole in the humidifier bag that hangs in between the tubing, he observed R28 was having difficulty breathing. F1 called the nurses and the West unit manager (UM) and another nurse did not know how to use the Ambu bag (a manual resuscitator, used to provide positive pressure ventilation to patients who are not breathing or not breathing adequately) to assist his father with breathing. The son stated he had to show the nurses how to use it. F1 stated those were just two (2) examples of how the staff were not taking care of R28. The son went on to state the facility did not have enough electrical sockets to plug in all of the equipment need for R28. He stated he had asked every day for two (2) weeks to get a power strip as staff keep unplugging the air mattress when they needed to plug something else in and would forget to plug the air mattress back in. He stated the air mattress was needed for R28 as he had two severe pressure ulcers. F1 stated he finally complained to the NHA and requested the power strip. F1 explained the NHA had stated he was unaware that this was an issue and he would find a power strip as soon as possible. The son reported it took a few more days after speaking to the NHA to get the power strip. Observation on 8/12/16, at approximately 12:45 p.m., when returning to observe R28 and do a cursory review of the room to ensure all necessary equipment for a patient with a [MEDICAL CONDITION] was available, he was observed lying slightly turned to his left side facing the window. He was lying on what appeared to be an air mattress with the head of the bed elevated at approximately a 30-degree angle. R28 had a [MEDICAL CONDITION] and received oxygen via a Tran'[MEDICAL CONDITION] set up which was on the right side of the bed when standing at the end of the bed facing R28. There was a humidifier bottle attached at the top of the tubing which was about one-quarter full. Further down the tubing, there was an air pouch which appeared to be a plastic bag humidifier attached that contained moisture. The two residents shared a room and both had tracheotomies. They were required to have replacement inner cannulas for the residents, in the event their [MEDICAL CONDITION] cannulas became dislodged and needed to be replaced to ensure adequate breathing. A facility Licensed Practical Nurse (LPN117) was providing wound care for R28, with the assistance of a Certified Nursing Assistant. When asked where the extra cannulas were stored, LPN117 indicated the top of a dresser, located on side of the room nearest R28. There were various supplies (dressings, tubing, etc.) jumbled together in a disorderly fashion. What was found by the surveyors were inner cannulas size 8 and size 6. R28 required a size 8 and R29 required a size 4. The room was crowded with equipment and supplies and a power strip was observed taped to the floor with multiple cords plugged into it. The suction machine was on the left side of the bed and back, there was other equipment in front of the suction machine. On 8/12/16, at approximately 1:00 p.m., the DON was interviewed and informed they did not have the proper sized inner cannulas in the room. She immediately went to the room with the same staff nurse (LPN117) observed during wound care, and returned with a size 4 cannula that she said was found in a drawer. That observation was not confirmed and the equipment needed to be readily accessible (as in taped above the bed of each [MEDICAL CONDITION] patient) was not available when surveyors observed the room. Nor was LPN117 able to verbalize where that cannula was when asked by the surveyor during the initial observation of the wound care for R28. The DON confirmed the following pieces of equipment were needed for R28: Oxygen concentrator to deliver oxygen [MEDICAL CONDITION]; A suction machine/aspirator (used to clear the airway of blood, saliva, mucus, vomit or other secretions); A pressure relieving air mattress (used to prevent pressure ulcers by dispersing pressure away from the affected areas and bony prominences); A nebulizer machine (a drug delivery device used to administer medication in the form of a mist inhaled into the lungs, or in the case of R28, used to deliver medication via his [MEDICAL CONDITION]); An intravenous (IV) administration set up (to infuse liquid substances directly in to a vein, for R28 it was used to administer antibiotics) - though not in use during the survey; A Negative-pressure wound therapy (NPWT) machine (a therapeutic technique using a vacuum dressing to promote healing in acute or chronic wounds and enhance healing of second and third degree burns); and An electric hospital bed (which allowed for raising and lowering of the bed itself, as well as the ability to raise and lower both the head and foot of the bed). On 8/12/16 at 1:45 p.m., staff physician 165 (primary care physician for R28) stated R28 was a very sick man when he was admitted due to having a Stage 4 and a Stage 2 pressure ulcer, as well as history of acute [MEDICAL CONDITION] and that he was a quadriplegic. Physician 165 stated he had suggested, on more than one occasion, that the son move R28 to a more prominent facility that was staffed with more skilled staff to [MEDICAL CONDITION] wound care, but the son refused to move his father. Physician 165 stated he also wanted the resident transferred to a higher acuity level of care as the wounds were not improving as much as he had wanted them to. He stated he was not consulted regarding whether or not to accept R28 into the facility. Physician 165 stated that he had many discussions with the son and had advised the family R28 would benefit from a facility that provides a higher level of care such as a hospital or long-term acute care (LTAC). He also stated that on 8/6/16 he had requested the resident go to the hospital to be evaluated by an infection disease doctor as he suspected R28 had a colonized infection in his trach. He explained the son requested they wait until the following Monday as he wanted to consult some others and decide if he wanted his father sent to the hospital. Physician 165 stated he did not receive a call back from the son, so he ordered a consult from an infectious disease physician to take place at the nursing home. He stated R28 was stable but he continued to believe the resident would benefit from a higher level of care, but family would not allow, so his best course of action was to request the consult 2. R29 was most recently admitted to the facility on [DATE] (he had resided there previously) with [DIAGNOSES REDACTED]. R29 was a readmit from an acute hospital stay. According to a progress note dated 5/23/16, and as documented on the care plan, R29 pulled his [MEDICAL CONDITION] out and was sent to hospital, where they replaced it and sent him back to the facility. Documentation showed the resident was not in respiratory distress and yet the facility still did not attempt to [MEDICAL CONDITION]. R29 was care planned for history of self extubation (removing his own trachea tubing and cannula) as a behavior, the facility did not have the appropriate size inner cannula ready at his bedside. As evidenced by documentation of having to be hospitalized for [REDACTED]. His Admission Minimum Data Set (MDS), competed on 5/20/16, showed R29 was extensively to totally dependent on staff for all ADLs. He was also fed via a gastrostomy feeding tube. Observation on 8/12/16, at approximately 12:45 p.m., R29 (roommate of R28) also had a [MEDICAL CONDITION]. Their supplies were co-mingled together on a dresser on the side of the room of R28. There was only one (1) Ambu bag present, and there should have been one (1) for each resident. They also needed to have back up inner cannulas readily accessible in the event [MEDICAL CONDITION] dislodged and needed to be replaced to ensure breathing. There were two (2) different sizes in the room - a size 8 and a size 6. R28 required a size 8 and R29 required a size 4. LPN117 (who was the facility wound care nurse) was asked where the needed cannulas might be, and stated they should be in the pile of supplies. She could not state the required size for each resident, so in the event of an emergency the correct sized inner cannula would not be used. Interview on 8/12/16, at approximately 3:36 p.m., the NHA stated that they did not have enough outlets for either resident (R28 or R29) to accommodate their medically necessary, physician ordered, equipment. He stated that when R28 (on 6/26/16) was admitted they realized they did not have enough outlets and directed the Maintenance Director to take and install a power strip in the room. The NHA stated that both R28 and R29 had more medical equipment than they had outlets for and the decision was made to unplug the air mattress for R28. He stated the air mattress was uninflated for a couple of days. (cross refer to F314). Therefore, R28 was admitted on [DATE], indicating a total of over thirteen (13) weeks, the facility had known that the R28 and R29 did not have enough electrical power outlets to support the ventilator equipment, other needed equipment including pressure prevention mattress for residents with pressure sores, and suctioning equipment. The NHA stated he had checked with the Fire Marshall and based on the amperage of the power strips, felt the need was met. He indicated he was not aware that a power strip could not be used in lieu of proper connectivity to the facility power source (the wall outlets). On 8/12/16, at approximately 1:00 p.m., the Director of Nursing (DON) was interviewed and confirmed the following pieces of equipment were needed for R29: Oxygen concentrator to deliver oxygen [MEDICAL CONDITION]; A suction machine/aspirator (used to clear the airway of blood, saliva, mucus, vomit or other secretions); A nebulizer machine (a drug delivery device used to administer medication in the form of a mist inhaled into the lungs; An electric hospital bed (which allowed for raising and lowering of the bed itself, as well as the ability to raise and lower both the head and foot of the bed), and: A feeding tube administration set up (to infuse liquid nourishment directly into his stomach via a gastrostomy tube). The DON had just started work at the facility approximately one week prior to the survey start date and had no direct observation of the specifics of the allegations made by F1 for R28, but was aware of the issues via record review and her nursing staff. She also stated she had heard there was a problem with having enough outlets for all needed medical equipment and they had power strips in place to meet their needs. She stated she was not aware that a power strip was contraindicated for use with medical equipment. On 8/13/16, at approximately 10:30 a.m., the Maintenance Director was interviewed with the NH[NAME] He confirmed he had been directed to install a power strip in the room of R28. He stated when he went to deliver the power strip, the staff were providing cares to R28, so he left the power strip at the West Wing Nurses station and the nursing staff was supposed to hook up the power strip. A few days went by before it was discovered the power strip had not been installed. The NHA also stated a few days went by before he was made aware of the fact the power strip had still not been installed. As soon as he was aware, he took immediate action to have it put in place. ***The facility implemented the following actions to remove the Immediate Jeopardy: II. Both residents (R28 and R29) identified were sent to the hospital on [DATE] for the needed higher level of care. The two identified residents R28 and R29 are no longer at this facility. A 100% room audit was completed for appropriate electrical audits by (MONTH) 13, (YEAR). Maintenance Department staff members were educated on the inability to use power strips for medical equipment on 8/12/16. The Plant Operations Director initiated staff education on the inability to use power strips with medical equipment on 8/12/16. The Plant Operations Director and/or designee will educate new staff members during the orientation process. Plant Operations Director and/or designee will perform monthly audits of all rooms looking for power strips and report findings to monthly QAPI committee meetings. Any variance will be addressed immediately. Rooms with red emergency electrical outlets were identified and given to the Admissions Coordinator for appropriate resident placement on 8/14/16. Identified with blue dots on our admission board located in admission department. Our Clinical Admission Grid was updated to reflect high risk respiratory residents would be reviewed by the DON before admission. No residents will be admitted into the facility with high acuity of tracheotomies until additional specialized training is completed for the licensed nurses. No residents will be admitted into the facility with high acuity of tracheotomies until additional specialized training is completed for the licensed nurses. A licensed respiratory therapist from (Name deleted) will be contracted to provide in-house education for the licensed nurses on [MEDICAL CONDITION] care and equipment. For future [MEDICAL CONDITION] residents admitted into the facility, an individualized [MEDICAL CONDITION] kit will be kept at the bedside of each resident. This will include replacement inner cannulas with the correct size. A skills check list will be developed and utilized by the DON and/or Registered Nurse designee to ensure the competency levels of license nurses providing care [MEDICAL CONDITION]. An Ad Hoc QAPI Committee Meeting was held on 8/12/16 to review and approve the plan. The plan was reviewed and approved by the Medical Director. ***The State survey agency validated the corrective action taken by the facility as follows: Review of physician orders [REDACTED]. Observation on 8/18/16 at 9:00 a.m. verified that both R28 and R29 were not in the facility. Interview on 8/18/16 at 9:05 a.m. with Admissions Coordinator verified that the facility had not admitted any future residents with higher acuity of tracheotomies until additional specialized training is completed for licensed nurses. Observation on 08/18/16 at 9:10 a.m. with DON, revealed that the Admission Grid was updated to include rooms that could be used to admit any future high risk respiratory tracheotomies (trach) residents to facility. The DON confirmed that the facility will not admit residents [MEDICAL CONDITION] trained Respiratory Therapist being on staff and all licensed nurses have completed specialized training. Review of a skills check list related to the treatment of [REDACTED]. Interview on 8/18/16 at 9:15 a.m. with DON and Admission Coordinator provided education to all licensed staff to ensure all high acuity residents with tracheotomies will not be admitted to the facility without trained Respiratory Therapist being on staff and all licensed nurses completed specialized training. Review of employee training education signature sheets verified the facility implemented new protocol on [MEDICAL CONDITION] for [MEDICAL CONDITION]. Interview on 8/18/16 at 9:25 a.m. the Nursing Home Administrator (NHA) confirmed he is actively recruiting respiratory therapist. Review of the Northeast Atlanta Health and Rehabilitation Center Electrical Safety/Non-Use of Power Strips for Medical Equipment log training log verified that two (2) of two maintenance staff received in-service training on electrical safety and the non-use of power strips for electrical equipment on 8/12/16. In addition, it was verified that ninety-six (96) of a total of one-hundred ninety-one (191) facility employees received in-service training on electrical safety and the non-use of power strips for electrical equipment on 8/12/16 and 8/13/16. Interview on 8/19/16 at 11:04 a.m. with the facility NHA confirmed a 100% room audit was completed for appropriate electrical outlets and all power strips were removed from resident rooms on/or before 8/13/16. Observation on 8/19/16 beginning at 11:04 a.m. with the facility NHA and Maintenance Director confirmed there were no power strips in any resident rooms on the East, West and Terrace Units of the facility therefore validating there were no rooms with power strips; the Admission Board, in the Admissions Office to have blue dots identifying a total of eight (8) rooms with red emergency electrical boxes capable of safely providing power to suctioning and similar equipment related to tracheotomy care. Review of the Ad Hoc QAPI (Quality Assurance and Performance Improvement) Committee Meeting signature sheet revealed all disciplines signatures were present. Interview on 11/8/16 at 1:00 p.m. via telephone with the Medical Director acknowledged becoming aware of the ventilator issues during the survey. He continued to state it is never ok to use a power strip for medical equipment, and the residents were immediately they were transferred. The facility presently will not admit any residents with trachs until sufficient training and the availability of a Respiratory Therapist for consultation. The Medical Director revealed that the QA Committee discussed Respiratory during the meetings held on 8/24/16, 9/21/16 and 10/12/16. Interview on 11/8/16 at 2:20 p.m. With the NHA and the DON revealed that they were not aware of the problems with the ventilator residents until the survey in (MONTH) (YEAR). Per DON she immediately located the correct cannula; re-organized the room and sorted their supplies and reported to the family and the physician. | 2019-11-01 |