cms_GA: 6284
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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 |
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6284 | COOK SENIOR LIVING CENTER | 115655 | 706 NORTH PARRISH AVE . | ADEL | GA | 31620 | 2015-02-05 | 490 | K | 1 | 0 | XT5M11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, facility document review, facility policy review, resident interview, and staff interview, facility administration failed to ensure supervision/monitoring regarding the smoking behaviors of four (4) residents (#1, A, B, and E) who were assessed as unsafe to smoke without staff supervision and/or who exhibited unsafe behaviors of either obtaining smoking paraphernalia from, or providing smoking paraphernalia to, other residents without the knowledge of facility staff. The total survey sample was nine (9) residents, all of whom smoked cigarettes, with a Smoker's List provided by the facility documenting a total of fifteen (15) residents who smoked. For Resident #1, who was assessed to require supervision while smoking, the facility failed to provide routine monitoring to address the resident's unsafe behavior of obtaining smoking paraphernalia from other residents (including Resident A) and either smoking, or attempting to smoke, unsupervised. For Resident B, who was restricted from maintaining smoking materials in her possession related to a history of unsafe lighter use, the facility failed to routinely monitor to prevent the resident from unsafely accessing smoking paraphernalia. For Resident E, who did not smoke upon facility admission, but then began to smoke cigarettes after admission and was assessed to require staff supervision while smoking, the facility failed to provide monitoring to ensure the resident's safety while smoking. The facility's Administrator and Director of Nursing (DON) were informed of the immediate jeopardy on January 30, 2015 at 12:00 p.m. The noncompliance related to the immediate jeopardy was identified to have existed on January 19, 2015, the date Resident #1, who was assessed by the facility to require staff supervision while smoking cigarettes, obtained two (2) cigarettes and gained access to a cigarette lighter without the knowledge of staff, attempted to light the cigarette with the lighter, and caught her hair on fire with the lighter. Resident #1 sustained multiple second/third [MEDICAL CONDITION] the left face, forehead, and ear. The immediate jeopardy continued through February 2, 2015, and was removed on February 3, 2015. The facility implemented a credible allegation of jeopardy removal related to the immediate jeopardy on February 2, 2015. An allegation of jeopardy removal was received on February 2, 2015. Based on the corrective plans which had been developed and implemented by the facility, the immediacy of the deficient practice was determined to have been removed on February 3, 2015. The facility remained out of compliance at a lower scope and severity of E while the process of evaluating modifications of resident assessment systems, care planning systems, and processes involved in the supervision of residents who smoked continued. In-service materials and records were reviewed. Interviews were conducted with staff to ensure they were knowledgeable about the facility's processes for supervising residents who smoked and who required supervision during smoking. Resident record reviews were conducted to assess facility staffs' conformance with the development of resident Plans of Care regarding smoking supervision. In addition, residents were observed while smoking in the exterior designated smoking area to assess facility staffs' conformance with the supervision of residents while smoking, in accordance with their assessed needs and as specified by their Plans of Care, to therefore ensure resident safety while smoking. Findings include: Cross refer to F323. Based on observation, record review, facility document review, facility policy review, resident interview, and staff interview, the facility failed to ensure supervision/monitoring related to cigarette smoking for Resident #1, who was assessed to require staff supervision while smoking; for Resident B, who could smoke without supervision but was not allowed to access or maintain smoking materials in her possession without staff supervision; and for Resident E, who began smoking cigarettes after facility admission and was assessed to require supervision while smoking, but for whom the facility failed to provide routine supervision to ensure the resident's safety. The total survey sample was nine (9) residents, all of whom smoked cigarettes. A Smoker's List provided by the facility documented a total of fifteen (15) residents who were identified by the facility to smoke cigarettes. The facility's failure to ensure adequate monitoring and supervision to residents who smoked resulted in 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. During an interview with the Administrator conducted on 02/02/2015 at 1:59 p.m., the January 19, 2015 incident during which Resident #1 obtained cigarettes and lighter without the knowledge of staff and subsequently sustained multiple burn wounds to the face, forehead, and ear was discussed. The facility's Smoking Policy and Procedure was discussed with the Administrator, and the Administrator was questioned about his involvement in oversight and implementation of the Smoking Policy. During this interview, the Administrator stated that in his position as Administrator, he was directly involved in overseeing the Smoking Policy and Procedure. He stated that he had received information through the DON related to resident smoking issues prior to the January 19, 2015 incident resulting in Resident #1's multiple burn wounds. He stated that after the January 19, 2015 incident resulting in Resident #1's burn wounds from a cigarette lighter, he remained involved in overseeing the Smoking Policy. The Administrator stated that after the January 19, 2015 incident, he implemented a new procedure on January 27, 2015 specifying that all resident smoking would be supervised, and would be documented and tracked via use of the Smoking Monitoring Log. The Administrator further stated that both he and the DON had instructed staff to be more vigilant with watching Resident #1 and Resident A after the January 19, 2015 incident, further referencing the January 24, 2015 incident when Resident A had again given Resident #1 a cigarette. However, the Administrator presented no evidence of the development and implementation of any specific method by which to track and evaluate direct-care staffs' monitoring and supervision of resident smoking activities (to include oversight of residents requiring supervision while smoking but who were known to exhibit the unsafe behavior of obtaining smoking paraphernalia without the knowledge of staff) prior to the January 19, 2015 incident during which Resident #1 obtained smoking smoking materials from Resident A and sustained multiple burns. In addition, no evidence was presented of development and implementation of a method of evaluation of direct-care staff oversight of resident smoking after the January, 19, 2015 incident involving Resident #1 obtaining smoking materials from Resident A, or after the January 24, 2015 incident when Resident A again provided Resident #1 with a cigarette, initially without the knowledge of facility staff. Based on the above, there was no evidence of a facility system, either prior to or after the January 19, 2015 incident resulting in Resident #1 obtaining multiple burn wounds while smoking unsupervised, until January 27, 2015 (after the January 23, 2015 initiation date of this abbreviated survey) which allowed for, and ensured, the ongoing oversight of direct-care staffs' supervision of residents who required supervision due to their assessed inability to smoke safely with supervision and/or who exhibited unsafe smoking behaviors and practices. The facility presented a credible allegation of jeopardy removal (CAJR) on February 2, 2015. Based on the CAJR, it was determined that the immediate jeopardy had been removed on February 3, 2015, at which time the facility had implemented the following interventions: 1. On 01/26/2015, the Quality Assessment and Assurance (QAA) Committee met. During this meeting, the QAA Committee reviewed the facility's current Smoking Policy and discussed revisions to enhance resident safety. Recommendations were made, and the DON was to make edits and submit the revised Policy for review and approval. The specific recommendation that all resident smoking would be monitored was discussed an initiated immediately. Additionally, the Committee discussed offering smoking cessation services to residents desiring such services. 2. On 01/27/2015, the QAA Committee met and the revisions to the Smoking Policy were submitted for review and approval. The QAA Committee meeting focused on the development of a Smoking Monitoring Log, with approval and implementation post meeting. This Smoking Monitoring Log would allow for the staff responsible for monitoring the smoking area (per the newly implemented procedure referenced above specifying that all resident smoking would be monitored) to document attendance and oversight during designated smoking times. The QAA Committee was informed that a smoking cessation instructor would begin services on that date, offering a general orientation to smoking cessation classes. 3. On 01/29/2015, the facility implemented the Smoking Policy, the Purpose of which is to provide guidance regarding resident smoking at the facility. This Smoking Policy includes, but is not limited to, the specification that resident smoking is only permitted under staff supervision. Residents will not be allowed to keep any smoking paraphernalia on their person or with their personal belongings. Residents are required to check smoking paraphernalia out from staff members with entrance to the designated smoking area, and check smoking paraphernalia back in with staff at the time of exit from the designated smoking area. No more than two (2) cigarettes may be distributed to a resident, and any cigarettes not smoked will be collected by staff and returned to the storage area upon reentry into the building. Lighters and matches will be distributed to the resident for that smoking session and collected by staff for storage upon reentry into the building. Smoking paraphernalia will be inventoried following every smoking session to ensure all is accounted for. This inventory will be completed by the staff member assigned to supervise at each scheduled smoking time, and will be documented on the Resident Tobacco and Paraphernalia Log. The sharing of cigarettes and/or lighters and matches amongst residents is not permitted. Smoking is not permitted except within the designated area which is the courtyard/patio area located on the facility's South wing. Resident smoking will be conducted during scheduled times via a Smoking Schedule, and the smoking area will be open for resident access based on the posted schedule. Additionally, the Smoking Policy specifies that residents will be assessed upon admission regarding smoking preferences and any special needs. Residents are then reassessed quarterly and with any change in condition. A Smoking Safety Evaluation Form will be utilized to conduct resident smoking assessments. This Smoking Safety Evaluation will be utilized to assess a resident's smoking history, safety concerns, cognitive awareness, and ability to handle a lighter. This assessment includes the evaluation of each smoking resident's capabilities and deficits and determines whether or not supervision during smoking is required. Based on the data collected in the smoking assessment, a specific plan will be developed to meet the individual needs of the resident. The information in the assessment is included in the resident's Plan of Care, which is reviewed and revised accordingly. 4. On 01/29/2015, the facility implemented the use of a new Safety Surveillance Log to be utilized in the event of resident non-compliance with the Smoking Policy. This new procedure indicated that, in the event a resident is observed in possession of tobacco and/or paraphernalia (other than at the approved times and in conformance with approved procedures), the facility would implement surveillance to ensure compliance. Said surveillance will be documented in the Safety Surveillance Log. At the time of discovery of an infraction, items will be inventoried for the resident. The Safety Surveillance Log will be completed as supervised by the designated Charge Nurse. The surveillance frequency will be a minimum of twice per day, and include a random search for a seven-day period. With zero findings for the seven-day period, the surveillance would transition to three times per week for 30 days. A reassessment will be conducted post the 30 day mark for the necessity of ongoing surveillance. In addition, an attempt will be made to identify the source of provision of products with subsequent counseling to follow. All findings and recommendations will be submitted to, and monitored by, the QAA Committee. 5. On 01/29/2015, a special called Resident Council meeting was held to discuss the changes to the Smoking Policy. All resident smokers were in attendance. 6. On 01/29/2015, all residents utilizing tobacco products were assessed by the DON using the new Smoking Safety Evaluation Form. One-hundred percent of all current residents who smoke (a total of fourteen residents on the date of assessment) were assessed with [REDACTED]. 7. On 01/29/2015, the facility reviewed/revised the Plans of Care for all residents using tobacco products, and Plans of Care for these residents were developed/updated with the goals of no injury when using tobacco products, safety practices, and encouraging smoking cessation. 8. On 01/29/2015, the facility reiterated a procedure requiring that the facility's Interdisciplinary Care Team reassess each resident who smoked on a quarterly basis, or more frequently if needed, to determine if any change in smoking abilities has occurred. All resident Plans of Care will be updated to reflect this assessment. 9. On 01/30/2015, a one-on-one sitter was assigned to Resident #1 to provide supervision to the resident. Resident #1 will have a sitter twenty-four hours per day, seven days per week to ensure her safety, and this coverage will continue until a later determination is made. 10. On 02/02/2015, the facility implemented the use of fire blankets (which were originally ordered by the facility on 01/30/2015). These fire blankets will be housed in the smoking area and will be used to aid in ensuring resident safety during smoking. 11. On 02/02/2015, the facility implemented enforcement of the Policy by which all smoking tobacco products and paraphernalia were removed from resident possession. Going forward, per the new Policy referenced above, smoking tobacco products and paraphernalia will be provided to residents upon request in the designated smoking area. When the resident reenters the facility after smoking activities have concluded, any smoking tobacco product that has not been consumed, as well as any smoking paraphernalia, will be returned to facility staff and inventoried. 12. On 02/02/2015, the facility conducted staff in-service training regarding the new Smoking Policy and the new procedures involving the supervision of residents who smoke, the new smoking schedule, the monitoring process for potential resident noncompliance, and resident safety while smoking by the use of fire blankets. This staff in-service training also included staff training related to the smoking assessment process. As of 02/02/2015, the following facility staff had received this in-service training: eighteen (18) of eighteen (18) housekeeping staff; fourteen (14) of fourteen (14) food service staff; three (3) of three (3) activities staff; forty (40) of forty (40) certified nursing assistants; and twenty-two (22) of twenty-three (23) licensed nursing staff. One (1) licensed nursing staff member was unavailable to receive this training due to being on leave status. This one (1) remaining licensed nursing staff member will receive this in-service training upon her return to work. 13. On 02/02/2015, the facility implemented the Smoking Policy Compliance Audit to audit the facility's new smoking program to monitor for evidence of ongoing staff compliance. This Audit will serve the purpose of monitoring and assessing staff compliance with the routine completion of the resident Smoking Safety Evaluation assessments, execution and maintenance of resident Plans of Care, the completion of the routine staff inventory of tobacco products and paraphernalia, and completion of the Smoking Surveillance Log (utilized as needed to address identified resident noncompliance with the Smoking Policy). This Smoking Policy Compliance Audit will be conducted by the DON, Assistant Director of Nursing, designated Registered Nurse Supervisor, Administrator, Assistant Administrator, or MDS Coordinator. This Audit will be conducted on every resident who smokes beginning on 02/02/2015, and will be conducted with the following progression: Weekly from 02/02/2015 through 02/28/2015; Biweekly from 03/01/2015 through 04/05/2015; Monthly on 04/06/2015, and ongoing. Any findings and subsequent interventions for ongoing compliance with facility Policy will be discussed with the QAA Committee. The data collected during the Smoking Policy Compliance Audit will be reported monthly to the QAA Committee for the Committee's review and evaluation. During this abbreviated survey, the State Survey Agency reviewed the corrective actions implemented by the facility, as reflected in the CAJR referenced above, with findings as follow: - On 02/03/2015, interview with the Administrator and review of QAA Committee attendance sheets confirmed that the facility's QAA Committee had convened to review the facility's Smoking Policy, discuss Policy revisions, and instruct the DON to make specified Policy changes. This was in accordance with Step #1 of the CAJR referenced above. - On 02/03/2015, interview with the Administrator and review of QAA Committee attendance sheets confirmed that the QAA Committee met for review and approval of the revisions to the Smoking Policy. This included the development and implementation of the Smoking Monitoring Log to be used by staff to ensure attendance and oversight during resident designated smoking times. This was in accordance with Step #2 of the CAJR referenced above. - On 02/03/2015, DON interview and Policy review confirmed that the facility had implemented a new, revised Smoking Policy with specifications which included the restriction of resident smoking to scheduled smoking times and under direct staff supervision only, the restriction of residents' possession of smoking paraphernalia in the absence of staff supervision. This Smoking Policy also specified a procedure involving residents obtaining smoking paraphernalia from staff when entering the smoking area and returning smoking paraphernalia to staff upon exiting the smoking area. This was in accordance with Step #3 of the CAJR referenced above. - On 02/03/2015, document review, Policy review, and interview with the DON confirmed that the facility had implemented the Safety Surveillance Log to be utilized in the event of resident noncompliance with the Smoking Policy (and to be used on an as-needed basis). This new Safety Surveillance Log and the accompanying procedure would allow staff to implement surveillance, via inspections at specified intervals for specified timeframes, to ensure resident compliance with the facility's Smoking Policy. This was in accordance with Step #4 of the CAJR referenced above. - On 02/03/2015, review of meeting minutes confirmed that the facility had met with the Resident Council to discuss the changes to the Smoking Policy, with all smokers in attendance, in accordance with Step #5 of the CAJR referenced above. - On 02/03/2015, and ongoing throughout the abbreviated survey, it was confirmed via record review that all facility residents who used tobacco products were assessed via the new Smoking Safety Evaluation Form. This was in conformance with Step #6 of the CAJR referenced above. - On 02/03/2015, and ongoing throughout the abbreviated survey, it was confirmed via record review that the facility had reviewed the Plans of Care for all residents using tobacco products, with Plan of Care additions and revisions made as needed. This was in accordance with Step #7 of the CAJR referenced above. - On 02/03/2015, Policy review confirmed the facility procedure which specified that the Interdisciplinary Care Team reassess residents who smoke on a quarterly basis, and more frequently if needed, regarding evaluation for changes in smoking abilities. Accompanying Plan of Care updates will be made. This was in accordance with Step #8 of the CAJR referenced above. - On 02/03/2015, review of the One on One Sitter Safety Log confirmed that a one-on-one sitter had been assigned to Resident #1 to supervise to the resident twenty-four hours per day seven days per week, in conformance with Step #9 of the facility's CAJR referenced above. - On 02/03/2015, observation and in-service record review confirmed that the facility had implemented the use of fire blankets to help ensure resident safety during smoking, as indicated in Step #10 of the CAJR referenced above. - On 02/03/2015, resident observations and review of inventory logs confirmed that the facility had removed all smoking tobacco products and paraphernalia from resident possession, and that smoking tobacco products and paraphernalia will be provided to residents by staff upon request in the designated smoking area. This was in accordance with Step #11 of the CAJR referenced above. - On 02/03/2015, review of facility in-service training records confirmed that staff in-service training had been provided to licensed nursing staff, certified nursing assistants, laundry staff, housekeeping staff, food service staff, and activities services staff regarding the facility's new procedures for the supervision of residents who smoke, the smoking schedule, and the monitoring process for resident noncompliance. This was in accordance with Step #12 of the CAJR referenced above. - On 02/03/2015, Policy review, monitoring log review, and DON interview confirmed that the facility had implemented, per the specified schedule, the Smoking Policy Compliance Audit to monitor staff compliance with the completion of Smoking Safety Evaluation assessments and Plans of Care, as well as completion of the staff tobacco products and paraphernalia inventory and Smoking Surveillance Log. This was in accordance with Step #13 of the CAJR referenced above. Based on these corrective actions which had been developed and implemented by the facility on 02/02/2015 as outlined in the facility's CAJR referenced above, and based on the State Survey Agency's review of these CAJR corrective actions to confirm implementation, it was determined that the immediacy of the deficient practice was removed on 02/03/2015. The effectiveness of the corrective action plans, however, could not be fully assessed at the time of survey exit to ensure ongoing application and completion, as outlined below: The facility developed and implemented a new Smoking Policy which, in part, limited resident smoking activities to scheduled times and only under the direct supervision of staff. Residents would no longer be allowed to keep smoking paraphernalia on their person or with their personal belongings. Rather, residents would be required to obtain smoking paraphernalia from staff when entering the outside designated smoking area to smoke, and then return all smoking paraphernalia to staff at the time of reentry into the building from the designated smoking area. Smoking paraphernalia would be inventoried by staff following every smoking session to ensure all was accounted for. On 02/02/2015, the facility implemented enforcement of the Policy by which all smoking tobacco products and paraphernalia were removed from residents' possession, and would instead be obtained directly from staff at the beginning of scheduled smoking times and returned to staff and inventoried at the conclusion of scheduled smoking times. However, the 02/02/2015 implementation date of this new Policy and procedure was on 02/02/2015, the day before the 02/03/2015 exit date of this abbreviated survey. Therefore, the facility's ongoing compliance with this process involving the restriction of resident tobacco product access and scheduled staff inventories to provide accountability of tobacco products and paraphernalia could not be fully assessed at the time of survey exit and will need further evaluation at a future time. Additionally, on 02/02/2015, the facility implemented the Smoking Policy Compliance Audit to be conducted by the DON, Assistant Director of Nursing, designated Registered Nurse Supervisor, Administrator, Assistant Administrator, or MDS Coordinator. This Audit would serve to provide management-level oversight of staff compliance with Smoking Safety Evaluation assessment completion, Plans of Care review and revision, tobacco products/paraphernalia inventory procedures, and completion of the Smoking Surveillance Log (when indicated). This management-level Audit would be conducted for every resident who smokes and would be completed weekly through 02/28/2015, then biweekly from 03/01/2015 through 04/05/2015, then monthly thereafter. However, this Smoking Policy Compliance Audit involving management-level oversight of facility staffs' compliance with the Smoking Policy and procedures was implemented on 02/02/2015, the day prior to the 02/03/2015 exit date of this abbreviated survey. Therefore, ongoing compliance with this management-level Audit procedure could not be fully assessed at the time of survey exit and will need further evaluation at a future time. Based on the above, due to the need for continued evaluation of the facility's corrective action plans to ensure ongoing effectiveness, application, and completion, the noncompliance continues, with the Scope and Severity reduced to the E level. | 2018-02-01 |